Center practice drives variation in choice of US kidney transplant induction therapy: a retrospective analysis of contemporary practice

Vikas R. Dharnidharka, Abhijit S. Naik, David A. Axelrod, Mark A. Schnitzler, Zidong Zhang, Sunjae Bae, Dorry Segev, Daniel Brennan, Tarek Alhamad, Rosemary Ouseph, Ngan N. Lam, Mustafa Nazzal, Henry Randall, Bertram L. Kasiske, Mara Ann McAdams Demarco, Krista L. Lentine

Research output: Contribution to journalArticle

Abstract

To assess factors that influence the choice of induction regimen in contemporary kidney transplantation, we examined center-identified, national transplant registry data for 166 776 US recipients (2005–2014). Bilevel hierarchical models were constructed, wherein use of each regimen was compared pairwise with use of interleukin-2 receptor blocking antibodies (IL2rAb). Overall, 82% of patients received induction, including thymoglobulin (TMG, 46%), IL2rAb (22%), alemtuzumab (ALEM, 13%), and other agents (1%). However, proportions of patients receiving induction varied widely across centers (0–100%). Recipients of living donor transplants and self-pay patients were less likely to receive induction treatment. Clinical factors associated with use of TMG or ALEM (vs. IL2rAb) included age, black race, sensitization, retransplant status, nonstandard deceased donor, and delayed graft function. However, these characteristics explained only 10–33% of observed variation. Based on intraclass correlation analysis, “center effect” explained most of the variation in TMG (58%), ALEM (66%), other (51%), and no induction (58%) use. Median odds ratios generated from case-factor adjusted models (7.66–11.19) also supported large differences in the likelihood of induction choices between centers. The wide variation in induction therapy choice across US transplant centers is not dominantly explained by differences in patient or donor characteristics; rather, it reflects center choice and practice.

Original languageEnglish (US)
Pages (from-to)198-211
Number of pages14
JournalTransplant International
Volume31
Issue number2
DOIs
StatePublished - Feb 1 2018

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Blocking Antibodies
Interleukin-2 Receptors
Transplants
Kidney
Tissue Donors
Delayed Graft Function
Living Donors
Therapeutics
Kidney Transplantation
Registries
Odds Ratio

Keywords

  • immunosuppression
  • induction
  • kidney transplantation
  • practice patterns

ASJC Scopus subject areas

  • Transplantation

Cite this

Dharnidharka, V. R., Naik, A. S., Axelrod, D. A., Schnitzler, M. A., Zhang, Z., Bae, S., ... Lentine, K. L. (2018). Center practice drives variation in choice of US kidney transplant induction therapy: a retrospective analysis of contemporary practice. Transplant International, 31(2), 198-211. https://doi.org/10.1111/tri.13079

Center practice drives variation in choice of US kidney transplant induction therapy : a retrospective analysis of contemporary practice. / Dharnidharka, Vikas R.; Naik, Abhijit S.; Axelrod, David A.; Schnitzler, Mark A.; Zhang, Zidong; Bae, Sunjae; Segev, Dorry; Brennan, Daniel; Alhamad, Tarek; Ouseph, Rosemary; Lam, Ngan N.; Nazzal, Mustafa; Randall, Henry; Kasiske, Bertram L.; McAdams Demarco, Mara Ann; Lentine, Krista L.

In: Transplant International, Vol. 31, No. 2, 01.02.2018, p. 198-211.

Research output: Contribution to journalArticle

Dharnidharka, VR, Naik, AS, Axelrod, DA, Schnitzler, MA, Zhang, Z, Bae, S, Segev, D, Brennan, D, Alhamad, T, Ouseph, R, Lam, NN, Nazzal, M, Randall, H, Kasiske, BL, McAdams Demarco, MA & Lentine, KL 2018, 'Center practice drives variation in choice of US kidney transplant induction therapy: a retrospective analysis of contemporary practice', Transplant International, vol. 31, no. 2, pp. 198-211. https://doi.org/10.1111/tri.13079
Dharnidharka, Vikas R. ; Naik, Abhijit S. ; Axelrod, David A. ; Schnitzler, Mark A. ; Zhang, Zidong ; Bae, Sunjae ; Segev, Dorry ; Brennan, Daniel ; Alhamad, Tarek ; Ouseph, Rosemary ; Lam, Ngan N. ; Nazzal, Mustafa ; Randall, Henry ; Kasiske, Bertram L. ; McAdams Demarco, Mara Ann ; Lentine, Krista L. / Center practice drives variation in choice of US kidney transplant induction therapy : a retrospective analysis of contemporary practice. In: Transplant International. 2018 ; Vol. 31, No. 2. pp. 198-211.
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abstract = "To assess factors that influence the choice of induction regimen in contemporary kidney transplantation, we examined center-identified, national transplant registry data for 166 776 US recipients (2005–2014). Bilevel hierarchical models were constructed, wherein use of each regimen was compared pairwise with use of interleukin-2 receptor blocking antibodies (IL2rAb). Overall, 82{\%} of patients received induction, including thymoglobulin (TMG, 46{\%}), IL2rAb (22{\%}), alemtuzumab (ALEM, 13{\%}), and other agents (1{\%}). However, proportions of patients receiving induction varied widely across centers (0–100{\%}). Recipients of living donor transplants and self-pay patients were less likely to receive induction treatment. Clinical factors associated with use of TMG or ALEM (vs. IL2rAb) included age, black race, sensitization, retransplant status, nonstandard deceased donor, and delayed graft function. However, these characteristics explained only 10–33{\%} of observed variation. Based on intraclass correlation analysis, “center effect” explained most of the variation in TMG (58{\%}), ALEM (66{\%}), other (51{\%}), and no induction (58{\%}) use. Median odds ratios generated from case-factor adjusted models (7.66–11.19) also supported large differences in the likelihood of induction choices between centers. The wide variation in induction therapy choice across US transplant centers is not dominantly explained by differences in patient or donor characteristics; rather, it reflects center choice and practice.",
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AU - Nazzal, Mustafa

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