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National Variation in Increased Infectious Risk Kidney Offer Acceptance

Holscher, Courtenay M. MD1; Bowring, Mary G. MPH1; Haugen, Christine E. MD1; Zhou, Sheng ScM, MBBS1; Massie, Allan B. PhD1,2; Gentry, Sommer E. PhD3; Segev, Dorry L. MD, PhD1,2,4; Garonzik Wang, Jacqueline M. MD, PhD1

doi: 10.1097/TP.0000000000002631
Original Clinical Science–General

Background. Despite providing survival benefit, increased risk for infectious disease (IRD) kidney offers are declined at 1.5 times the rate of non-IRD kidneys. Elucidating sources of variation in IRD kidney offer acceptance may highlight opportunities to expand use of these life-saving organs.

Methods. To explore center-level variation in offer acceptance, we studied 6765 transplanted IRD kidneys offered to 187 transplant centers between 2009 and 2017 using Scientific Registry of Transplant Recipients data. We used multilevel logistic regression to determine characteristics associated with offer acceptance and to calculate the median odds ratio (MOR) of acceptance (higher MOR indicates greater heterogeneity).

Results. Higher quality kidneys (per 10 units kidney donor profile index; adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.92-0.95), higher yearly volume (per 10 deceased donor kidney transplants; aOR, 1.08, 95% CI, 1.06-1.10), smaller waitlist size (per 100 candidates; aOR, 0.97; 95% CI, 0.95-0.98), and fewer transplant centers in the donor service area (per center; aOR, 0.88; 95% CI, 0.85-0.91) were associated with greater odds of IRD acceptance. Adjusting for donor and center characteristics, we found wide heterogeneity in IRD offer acceptance (MOR, 1.96). In other words, if listed at a center with more aggressive acceptance practices, a candidate could be 2 times more likely to have an IRD kidney offer accepted.

Conclusions. Wide national variation in IRD kidney offer acceptance limits access to life-saving kidneys for many transplant candidates.

1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

2 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.

3 Department of Mathematics, United States Naval Academy, Annapolis, MD.

4 Scientific Registry of Transplant Recipients, Minneapolis, MN.

Received 1 November 2018. Revision received 21 December 2018.

Accepted 30 December 2018.

The authors declare no conflicts of interest.

This research was supported by the National Institute of Diabetes and Digestive and Kidney Diseases grants: F32DK109662 (to C.M.H.), K01DK101677 (A.B.M.), K24DK101828 (D.L.S.), R01DK111233 (D.L.S.), and K23DK115908 (J.M.G.W.); the National Institute on Aging grant F32AG053025 (C.E.H.); and an American College of Surgeons Resident Research Scholarship (C.M.H.).

The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the SRTR, United Network for Organ Sharing/OPTN, or the US Government.

C.M.H., M.G.B., and J.M.G.W. participated in research design, analysis, writing, and critical revision. C.E.H. participated in research design, writing, and critical revision. S.Z. and A.B.M. participated in research design, analysis, and critical revision. S.E.G. and D.L.S. participated in research design and critical revision.

Correspondence: Jacqueline M. Garonzik Wang, MD, PhD, Department of Surgery, Johns Hopkins Medical Institutions, 2000 E Monument St, Baltimore, MD 21205. (

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