移植中心容量与 3 年临床结果的相关性。
Association of Kidney Transplant Center Volume With 3-Year Clinical Outcomes.
机构信息
Department of Surgery, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA.
Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA.
出版信息
Am J Kidney Dis. 2019 Oct;74(4):441-451. doi: 10.1053/j.ajkd.2019.02.019. Epub 2019 May 7.
RATIONALE & OBJECTIVE: A robust relationship between procedure volume and clinical outcomes has been demonstrated across many surgical fields. This study assessed whether a center volume-outcome relationship exists for contemporary kidney transplantation, specifically for diabetic recipients, older recipients (aged ≥65 years), and recipients of high kidney donor profile index (KDPI ≥ 85) kidneys.
STUDY DESIGN
Retrospective cohort study.
SETTING & PARTICIPANTS: Adult kidney-only transplant recipients who underwent transplantation between 2009 and 2013 (N = 79,581).
EXPOSURES
The primary exposure variable was center volume, categorized into quartiles based on the total kidney transplantation volume. Quartile 1 (Q1) centers performed a mean of fewer than 66 kidney transplantations per year, whereas Q4 centers performed a mean of more than 196 kidney transplantations per year.
OUTCOMES
All-cause graft failure and mortality within 3 years of transplantation.
ANALYTICAL APPROACH
Multivariable Cox frailty models were used to adjust for donor characteristics, recipient characteristics, and cold ischemia time.
RESULTS
Minor differences in rates of 3-year deceased donor all-cause graft failure across quartiles of center volume were observed (14.9% for Q1 vs 16.7% for Q4), including in subgroups (diabetic recipients, 18.4% for Q1 vs 19.7% for Q4; older recipients, 19.4% for Q1 vs 22.5% for Q4; recipients of high KDPI kidneys, 26.5% for Q1 vs 26.5% for Q4). Results were similar for 3-year mortality. After adjustment for donor, recipient, and graft characteristics using Cox regression, center volume was not significantly associated with all-cause graft failure or mortality within 3 years, except that diabetic recipients at Q3 centers had slightly lower mortality (compared with Q1 centers, adjusted HR of 0.85 [95% CI, 0.73-0.99]).
LIMITATIONS
Potential unmeasured confounding from patient comorbid conditions and organ selection.
CONCLUSIONS
These findings provide little evidence that care in higher volume centers is associated with better adjusted outcomes for kidney transplant recipients, even in populations anticipated to be at increased risk for graft failure or death.
背景与目的
在许多外科领域，已经证明手术量与临床结果之间存在稳健的关系。本研究评估了当代肾移植是否存在中心容量-结果关系，特别是对于糖尿病受者、年龄≥65 岁的受者和高肾供体评分指数（KDPI≥85）受者。
研究设计
回顾性队列研究。
地点和参与者
2009 年至 2013 年间接受单纯肾脏移植的成年受者（n=79581）。
暴露
主要暴露变量是中心容量，根据肾移植总量分为四分位数。第 1 四分位数（Q1）中心每年进行的肾移植平均少于 66 例，而第 4 四分位数（Q4）中心每年进行的肾移植平均多于 196 例。
结果
移植后 3 年内全因移植物失败和死亡。
分析方法
多变量 Cox 脆弱性模型用于调整供体特征、受者特征和冷缺血时间。
结果
观察到中心容量四分位数之间 3 年内死亡供体全因移植物失败的发生率存在微小差异（Q1 为 14.9%，Q4 为 16.7%），包括亚组（糖尿病受者，Q1 为 18.4%，Q4 为 19.7%；老年受者，Q1 为 19.4%，Q4 为 22.5%；高 KDPI 供体受者，Q1 为 26.5%，Q4 为 26.5%）。3 年内死亡率的结果相似。使用 Cox 回归调整供体、受者和移植物特征后，中心容量与 3 年内全因移植物失败或死亡无关，除了 Q3 中心的糖尿病受者死亡率略低（与 Q1 中心相比，调整后的 HR 为 0.85 [95%CI，0.73-0.99]）。
局限性
潜在的无法衡量的混杂因素，如患者合并症和器官选择。
结论
这些发现几乎没有证据表明，在更高容量的中心接受治疗与肾移植受者调整后结局更好相关，即使在预期移植物失败或死亡风险增加的人群中也是如此。
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