Center volume affects outcomes of pediatric kidney transplantation

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Higher-volume transplantation centers achieve better outcomes in children undergoing kidney transplantation, according to a study in Kidney Medicine.

The case-cohort study included data on 3762 kidney transplants in patients <18 years between 2010 and 2015, drawn from the Scientific Registry of Transplant Recipients. Procedures were performed at 115 centers, which were classified as low-volume (fewer than four transplantations per year), intermediate-volume (four to eight per year), and high-volume (more than eight per year). The 3-year graft survival was compared among these volume groups, with adjustment for covariates.

The three groups of recipients were similar in terms of sex, age, ethnicity, kidney disease diagnosis, and kidney donor profile index score. The analysis included 2379 deceased-donor and 1383 living-donor transplantations.

The 3-year graft survival was 92.1% at centers performing a high volume of procedures, compared with 90.3% at intermediate-volume centers and 88.4% at low-volume centers. The number needed to harm was 27: for every 27 children treated at a low-volume versus high-volume center, there would be 1 additional patient with graft loss. The graft survival rates were better at centers in high-income versus low-income states, with no interaction between household income and center volume.

Center volume was related to the outcomes of living-donor transplantation: 3-year graft survival was 91.7% at low-volume and intermediate-volume centers combined, compared with 95.3% at high-volume centers. There was no significant difference in outcomes of deceased-donor transplantation: about 89% in all three groups.

A recent study reported similar outcomes of adult kidney transplantation for centers performing differing volumes of transplantation procedures. Little is known about how center volume affects the outcomes of pediatric kidney transplantation, which constitute only about 2% of procedures nationwide.

The new study finds lower 3-year graft survival in children undergoing kidney transplantation at lower-volume centers. The effect of volume is most marked for living-donor kidney transplantations. The 1-month survival is similar across volume groups. This finding “argues against surgical factors being a key factor and suggests that limited experience may compromise the optimal handling of immunosuppression and prevention of infection accounting for the differences in 3-year graft survival,” the researchers write [Contento MN, et al. Center volume and kidney transplant outcomes in pediatric patients. Kidney Med doi: 10.1016/j.xkme.2020.01.008].