Maximizing Utilization in Pancreas Transplantation: Phenotypic Characteristics Differentiating Aggressive from Nonaggressive Transplant Centers

Background Maximizing pancreas utilization requires a balance between judicious donor selection and transplant center aggressiveness. We sought to determine how such aggressiveness affects transplant outcomes. Methods Using the Scientific Registry of Transplant Recipients, we studied 28 487 deceased-donor adult pancreas transplants. Donor and recipient demographic factors indicative of aggressiveness were used to score center aggressiveness. We compared outcomes of low (> 1 SD below mean), medium (+/- 1 SD from mean), and high (> 1 SD above mean) aggressiveness centers using bivariate and multivariable regression. Results Donor and recipient aggressiveness demonstrated a roughly linear relationship (R2 = 0.20). Center volume correlated moderately with donor (rs = 0.433) and recipient (rs = 0.270) aggressiveness. In bivariate analysis, there was little impact of donor selection aggressiveness on graft survival. Further, for simultaneous pancreas and kidney transplants, centers with greater recipient aggressiveness selection had better graft survival. High volume centers had better graft survival than low volume centers. In multivariable analysis, donor aggressiveness did not have an effect on graft survival; whereas graft survival for medium (HR 0. 66, CI 0.53-0.83) and high (HR 0.67, CI 0.51-0.86) recipient aggressiveness performed better than low aggressiveness centers. There was a clear volume effect, with high volume centers (>20 transplants/year, HR 0.69, CI 0.61-0.79) performing better than low volume centers. Conclusions Center practice patterns using higher risk donors and recipients did not negatively affect outcomes. This effect is likely mediated through efficiencies gained with the increased transplant volumes at these centers. Received 26 February 2018. Revision received 23 May 2018. Accepted 12 June 2018. Presented at the 16th International Congress of the International Pancreas and Islet Transplant Association (Oxford, United Kingdom), June 21-24, 2017. Correspondence: Oscar K. Serrano, MD, MBA, University of Minnesota, Division of Transplantation, Department of Surgery, Mayo Mail Code 195, 420 Delaware Street SE, Minneapolis, MN 55455. Email: serra061@umn.edu 1. Authorship: •Participated in research design: Serrano, Vock, Finger. •Participated in the writing of the paper: Serrano, Finger. •Participated in the editing of the paper: Serrano, Vock, Dunn, Kandaswamy, Finger. •Participated in the performance of the research: Serrano, Vock, Dunn, Kandaswamy, Finger. •Contributed new reagents or analytic tools: Vock, Finger •Participated in data analysis: Serrano, Vock, Finger. 2. Disclosure: The authors declare no conflicts of interest. 3. Funding: The authors declare no funding received for this work. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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