Leveraging marginal structural modeling with Cox regression to assess the survival benefit of accepting vs declining kidney allograft offers

Jordana B. Cohen*, Vishnu Potluri, Paige M. Porrett, Ruohui Chen, Marielle Roselli, Justine Shults, Deirdre L. Sawinski, Peter P. Reese

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Existing studies evaluating the survival benefit of kidney transplantation were unable to incorporate time–updated information on decisions related to each organ offer. We used national registry data, including organ turndown data, to evaluate the survival benefit of accepting vs turning down kidney offers in candidates waitlisted from 2007-2013. Among candidates who declined their first offer, only 43% ultimately received organ transplantations. Recipients who later underwent organ transplantation after declining their first offer had markedly longer wait times than recipients who accepted their first offer, and 56% received kidney transplants that were of similar or lower quality compared to their initial offer. In marginal structural modeling analyses accounting for time-updated offer characteristics (including Kidney Donor Profile Index, Public Health System risk status, and pumping), after 3 months posttransplant, there was a significant survival benefit of accepting an offer (adjusted hazard ratio 0.76, 95% confidence interval 0.66-0.89) that was similar among diabetics, candidates aged >65 years, and candidates living in donor service areas with the longest waitlist times. After carefully accounting for the effect of donor quality, we confirm that the survival benefit of accepting an organ offer is clinically meaningful and persistent beyond 3 months post–kidney transplantation, including high-risk subgroups of organ transplantation candidates.

Original languageEnglish (US)
Pages (from-to)1999-2008
Number of pages10
JournalAmerican Journal of Transplantation
Issue number7
StatePublished - Jul 2019


  • clinical research/practice
  • donors and donation: deceased
  • epidemiology
  • kidney (allograft) function/dysfunction
  • kidney transplantation/nephrology
  • organ acceptance
  • organ procurement and allocation
  • patient survival

ASJC Scopus subject areas

  • Transplantation
  • Pharmacology (medical)
  • Immunology and Allergy


Dive into the research topics of 'Leveraging marginal structural modeling with Cox regression to assess the survival benefit of accepting vs declining kidney allograft offers'. Together they form a unique fingerprint.

Cite this