Assessment of Variation in Live Donor Kidney Transplantation Across Transplant Centers in the United States

Background. Transplant centers vary in the proportion of kidney transplants performed using live donors. Clinical innovations that facilitate live donation may drive this variation. Methods. We assembled a cohort of renal transplant candidates at 194 US centers using registry data from 1999 to 2005. We measured magnitude of live donor kidney transplantation (LDKTx) through development of a standardized live donor transplantation ratio (SLDTR) at each center that accounted for center population differences. We examined associations between center characteristics and the likelihood that individual transplant candidates underwent LDKTx. To identify practices through which centers increase LDKTx, we also examined center characteristics associated with consistently being in the upper three quartiles of SLDTR. Results. The cohort comprised 148,168 patients, among whom 34,593 (23.3%) underwent LDKTx. In multivariable logistic regression, candidates had an increased likelihood of undergoing LDKTx at centers with greater use of unrelated donors (defined as nonspouses and nonfirst-degree family members of the recipient; odds ratio [OR] 1.31 for highest vs. lowest use; P=0.02) and at centers with programs to overcome donor-recipient incompatibility (OR 1.33; P=0.01). Centers consistently in the upper three SLDTR quartiles were also more likely to use unrelated donors (OR 8.30 per tertile of higher use; P<0.01), to have incompatibility programs (OR 4.79, P<0.01), and to use laparoscopic nephrectomy (OR 2.53 per tertile of higher use; P=0.02). Conclusion. Differences in center population do not fully account for differences in the use of LDKTx. To maximize opportunities for LDKTx, centers may accept more unrelated donors and adopt programs to overcome biological incompatibility.