Continuous Monitoring of Transplant Center Performance: Different Options for Different Goals.

BACKGROUND: In France, the need for continuous monitoring of transplant center performance has recently become apparent. Cumulative sum (CUSUM) monitoring of transplantation is already been used to monitor transplant outcomes in the United Kingdom and in the United States. Because CUSUM monitoring can be applied by different methods, the objective was to assess and compare the performance of different CUSUM methods for detecting higher than expected (ie, excessive) graft failure rates. METHODS: Data come from the French transplant registry. Lung and kidney transplants in 2011-2013 constituted the control cohort, and those in 2014-2016 the observed cohort. The performance of CUSUM monitoring, according to center type and predefined control limits, was measured by simulation. The outcome monitored was 3-month graft failure. RESULTS: In a low-volume center with a low failure rate, 3 different types of control limits produced successful detection rates of excessive graft failures of 15%, 62%, and 73% and false alarm rates of 5%, 40%, and 52%, with 3, 1, and 1 excess failures necessary before a signal occurred. In a high-volume center with a high failure rate, successful detection rates were 83%, 93%, and 100% and false alarm rates were 5%, 16%, and 69%, with 6, 13, and 17 excess failures necessary before a signal occurred. CONCLUSIONS: CUSUM performances vary greatly depending on the type of control limit used. A new control limit set to maximize specificity and sensitivity of detection is an appropriate alternative to those commonly used. Continued attention is necessary for centers with characteristics making it difficult to obtain adequate sensitivity or sufficiently prompt response.

The case to abandon human leukocyte antigen matching for kidney allocation: would it be wise to throw out the baby with the bathwater?

Since major histocompatibility (MHC) antigen matching was introduced in the early 1970s as the key factor determining kidney transplant allocation, several studies, mainly arising from organ-sharing organizations in the United States and Europe, have debated this complex issue. The first fundamental concern is the interaction of human leukocyte antigen matching with other transplant outcome risk factors, for example, prolongation of ischemia and matching for age. Much concordant data advocate restraining MHC antigen-based allocation in terms of space and time limits. The second fundamental concern is the balancing of the advantages of better antigen matching in terms of improved graft survival and the improved transplantation rate in immunologically high-risk patients with the major drawback of inequitable access for ethnic minorities and patients with rare MHC haplotypes. These issues have led to considering renewed kidney allocation rules, discarding human leukocyte antigen matching from algorithms, or modifying the specificity allocation level by using cross-reactive group matching or class II MHC antigen matching. The evolving concepts in the field of histocompatibility support the need for periodically updated, flexible, and hybrid allocation systems, as designed in France by the Etablissement français des Greffes.