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B.J.Orandi, J.M.Garonzik-Wang, A.B.Massie, A.A.Zachary, J.R.Montgomery, K.J.Van Arendonk, M.D.Stegall, S.C.Jordan, J.Oberholzer, T.B.Dunn, L.E.Ratner, S.Kapur, R.P.Pelletier, J.P.Roberts, M.L.Melcher, P.Singh, D.L.Sudan, M.P.Posner, J.M.El-Amm, R.Shapiro, M.Cooper, G.S.Lipkowitz, M.A.Rees, C.L.Marsh, B.R.Sankari, D.A.Gerber, P.W.Nelson, J.Wellen, A.Bozorgzadeh, A.O.Gaber, R.A.Montgomery and D.L.Segev

Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Programspecific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n¼185), positive flow, negative cytotoxic crossmatch (PFNC) (n¼536) or positive cytotoxic crossmatch (PCC) (n¼304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR]¼1.64, 95% confidence interval [CI]: 1.15–2.23, p¼0.007) and PCC (aHR¼5.01, 95% CI: 3.71–6.77, p<0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR¼2.04; 95% CI: 1.28–3.26; p¼0.003) and PCC (aHR¼4.59; 95% CI: 2.98–7.07; p<0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT’s effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT’s increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.

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