Variations in Center-level Practices Across US Transplant Centers Are Associated With Time to Relisting and Retransplantation in Patients With Graft Failure

Abstract

Rationale & Objective

There is known variability in the management of kidney transplant recipients facing graft failure. We hypothesized that variations in the timing of care transitions, immunosuppression weaning, and re-evaluation processes would be associated with differential access to retransplantation and relisting.

Study Design

An observational study.

Setting & Participants

Survey directed at medical directors of US transplant centers.

Exposures

Transplant center-reported practices.

Outcomes

Time to retransplantation (and secondarily, relisting) after graft failure.

Analytical Approach

Adjusted proportional hazards models with clustering by transplant center.

Results

Of the 178 surveyed centers, 77 unique transplant centers (43%) responded. Respondents reported significant variability in the timing of transition of patients back to general nephrologists (ranging from within 1 year of transplantation to never), weaning of immunosuppression with graft failure, and approach to assessments of frailty and adherence during the evaluation for relisting. Transplant centers that transitioned patients back to general nephrologists >3 to <5 years after transplant had lower likelihood of retransplantation (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73-0.88) and relisting (HR, 0.80; 95% CI, 0.75-0.85) compared with centers that transitioned patients earlier (between 1-3 years of transplantation). Transplant centers that did not oversee weaning of immunosuppression after graft failure had patients with a lower likelihood of retransplantation (HR, 0.89; 95% CI, 0.79-0.99) and relisting (HR, 0.88; 95% CI, 0.82-0.95) compared with centers that oversaw this weaning. Withdrawal of immunosuppression 12-24 months after return to dialysis was associated with a higher likelihood of retransplantation (HR, 1.28; 95% CI, 1.14-1.43) and relisting (HR, 1.15; 95% CI, 1.06-1.26) compared with withdrawal of immunosuppression within 6 months of graft failure.

Limitations

Observational nature of data and potential for residual confounding.

Conclusions

There is significant variation in the management of patients with graft failure across US transplant centers during the transition of care, and this variation was associated with differential access of patients to retransplantation and relisting.

Plain-Language Summary

Transplant centers vary in how they approach the management of transplant recipients with low kidney function facing graft failure. In this study, we surveyed transplant centers about their practices when working with patients with impending graft failure and linked these practices to access of patients to relisting and retransplantation using the national end-stage kidney disease registry. Respondents reported significant variability in the timing of the transition of care for transplant recipients back to general nephrologists, weaning of immunosuppression with graft failure, and approach to assessments of frailty and adherence during the evaluation for relisting and retransplantation. These variations in practice were often associated with differential access of patients to relisting and retransplantation.