The National Landscape of Living Kidney Donor Follow-Up in the United States

Abstract

In 2013, the Organ Procurement and Transplantation Network (OPTN)/ United Network for Organ Sharing (UNOS) mandated that transplant centers collect data on living kidney donors (LKDs) at 6 months, 1 year, and 2 years postdonation, with policy-defined thresholds for the proportion of complete living donor follow-up (LDF) data submitted in a timely manner (60 days before or after the expected visit date). While mandated, it was unclear how centers across the country would perform in meeting thresholds, given potential donor and center-level challenges of LDF. To better understand the impact of this policy, we studied Scientific Registry of Transplant Recipients data for 31,615 LKDs between January 2010 and June 2015, comparing proportions of complete and timely LDF form submissions before and after policy implementation. We also used multilevel logistic regression to assess donor- and center-level characteristics associated with complete and timely LDF submissions. Complete and timely 2-year LDF increased from 33% prepolicy (January 2010 through January 2013) to 54% postpolicy (February 2013 through June 2015) (p < 0.001). In an adjusted model, the odds of 2-year LDF increased by 22% per year prepolicy (p < 0.001) and 23% per year postpolicy (p < 0.001). Despite these annual increases in LDF, only 43% (87/202) of centers met the OPTN/UNOS-required 6-month, 1-year, and 2-year LDF thresholds for LKDs who donated in 2013. These findings motivate further evaluation of LDF barriers and the optimal approaches to capturing outcomes after living donation.

Keywords: Organ Procurement and Transplantation Network (OPTN); ethics and public policy; health services and outcomes research; kidney transplantation/nephrology; kidney transplantation: living donor.

© 2017 The American Society of Transplantation and the American Society of Transplant Surgeons.

Figures

Figure 1. Timely and complete LDF for LKDs January 2010 – June 2015

The proportion of timely and complete LDF forms increased every year for each form type. Timely and complete 6-month LDF form submissions increased from 45% for clinical forms in 2010 to 81% in 2015. Similarly, timely/complete submissions for 6-month laboratory forms increased from 36% in 2010 to 76% in 2015.

Figure 2. Proportion of transplant centers compliant with LDF form submission for LKDs February 2013 – June 2015

Some transplant centers submitted complete information outside of the 120-day reporting period. These centers were marked as near compliant in the figure. Some centers were compliant with 6-month LDF for the 2013 cohort but non-compliant for a later LDF reporting time. On the other hand, some centers were non-compliant with 6-month LDF reporting but compliant with later time points. Thus, while there seems to be little change in the proportion of transplant centers in the 2013 cohort between 6-month, 1-, and 2-year follow-up, only 43% of centers were fully compliant in this cohort.

Figure 3. Distribution of timely and complete LDF among transplant centers for LKDs February 2013 – June 2015

The variation in LDF form submission among centers persisted over time. A number of non-compliant centers were close to meeting the minimum thresholds for compliance, but several centers fell far below these requirements even as the thresholds increased each year. The minimum thresholds were 60% for clinical data and 50% for lab data on LKDs who donated in 2013, 70% for clinical data and 60% for lab data on LKDs who donated in 2014, and 80% for clinical data and 70% for lab data on LKDs who donated in 2015.

Figure 4. Transplant center-level variability in non-timely or incomplete 6-month LDF for LKDs February 2013 – June 2015

Center-level probabilities for a reference donor are represented by dots and calculated from empirical Bayes estimates. The reference donor is female, between 35–54 years old, non-African-American, non-Hispanic, had no history of hypertension or smoking prior to donation, married, spouse of kidney recipient, obtained a college degree, was working for income at the time of donation, was insured at the time of donation, had BMI between 19–24 at the time of donation, had eGFR ≥ 100 prior to donation, went to a small transplant center (1–19 donors/year), donated in 2015, and currently lives in-state. These figures demonstrate that the same donor could have had very different experiences with LDF depending on which transplant center she attended.

Figure 4. Transplant center-level variability in non-timely or incomplete 6-month LDF for LKDs February 2013 – June 2015

Center-level probabilities for a reference donor are represented by dots and calculated from empirical Bayes estimates. The reference donor is female, between 35–54 years old, non-African-American, non-Hispanic, had no history of hypertension or smoking prior to donation, married, spouse of kidney recipient, obtained a college degree, was working for income at the time of donation, was insured at the time of donation, had BMI between 19–24 at the time of donation, had eGFR ≥ 100 prior to donation, went to a small transplant center (1–19 donors/year), donated in 2015, and currently lives in-state. These figures demonstrate that the same donor could have had very different experiences with LDF depending on which transplant center she attended.