Defining pre-emptive living kidney donor transplantation as a quality indicator

Quality indicators in kidney transplant are needed to identify care gaps and improve access to transplant. We used linked administrative healthcare databases to examine multiple ways of defining pre-emptive living donor kidney transplants, including different patient cohorts and censoring definitions. We included adults from Ontario, Canada with advanced chronic kidney disease between January 1, 2013 to December 31, 2018. We created four unique incident patient cohorts, varying the eligibility by risk of progression to kidney failure and whether individuals had a recorded contraindication to kidney transplant (e.g., home oxygen use). We explored the effect of four censoring event definitions. Across the 4 cohorts, size varied substantially from 20,663 to 9,598 patients, with the largest reduction (a 43% reduction) occurring when we excluded patients with ≥1 recorded contraindication to kidney transplantation. The incidence rate (per 100 person-years) of pre-emptive living donor kidney transplant varied across cohorts from 1.02 (95% CI: 0.91,1.14) for our most inclusive cohort to 2.21 (95% CI: 1.96, 2.49) for the most restrictive cohort. Our methods can serve as a framework for developing other quality indicators in kidney transplantation and to monitor and improve access to pre-emptive living donor kidney transplant in healthcare systems.