Survival on hemodialysis versus renal transplantation following primary renal allograft failure

Late Renal Transplant Failure: An Adverse Prognostic Factor at Initiation of Peritoneal Dialysis

Background

Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis.

Objective

To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant.

Setting

Peritoneal dialysis (PD) unit in a teaching hospital.

Patients and Design

All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998.

Results

There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group ( p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease.

Conclusions

W e conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.

Risk of death following kidney allograft failure: a systematic review and meta-analysis of cohort studies

BACKGROUND

People with kidney allograft failure represent an increasing fraction of all those starting dialysis therapy. We sought to summarize prognosis following kidney allograft failure and identify potentially beneficial interventions or modifiable risk factors.

METHODS

We searched MEDLINE and EMBASE (inception to 1 October 2013) and article reference lists without language restriction and selected cohort studies of all-cause mortality and fatal infection-related and cardiovascular events in people starting dialysis following kidney allograft failure. Two reviewers independently extracted data on study design, participant characteristics, dialysis modality, transplant nephrectomy, immunosuppression strategy, transplant-naive comparators and risk of bias. Discrepancies were resolved with a third reviewer.

RESULTS

Forty studies comprising 249 716 participants met the inclusion criteria. The first year of dialysis therapy was associated with the highest mortality. By random effects meta-analysis, annual risk of death, from years 1 to 4, was 0.12 [95% confidence interval (95% CI): 0.09-0.15], 0.06 (95% CI: 0.05-0.07), 0.05 (95% CI: 0.04-0.06) and 0.05 (95% CI: 0.04-0.06), respectively. We found high heterogeneity in each meta-analysis, which remained unexplained by prespecified subgroup analyses. We could not find sufficient information to summarize the risk for fatal infection-related and cardiovascular events, or to test the role of transplant nephrectomy or different immunosuppressive strategies. Risk of bias was high, especially participation bias.

CONCLUSION

Mortality is higher during the first year of dialysis treatment following kidney allograft failure than in subsequent years. Insufficient data are available to assess factors or interventions potentially impacting prognosis following kidney allograft failure. In a culture promoting transplantation, clinical research of different models of care in this growing high-risk population should be a research priority.

Survival on dialysis post-kidney transplant failure: results from the Scientific Registry of Transplant Recipients

BACKGROUND

A substantial number of patients return to dialysis therapy after a renal transplant fails. It is not clear whether mortality increases among patients with graft failure relative to those on the waiting list who have not yet received a kidney transplant.

METHODS

Data from the Scientific Registry of Transplant Recipients were analyzed (N = 175,436). Cox regression with time-dependent covariates was used to compare mortality between post-graft failure dialysis patients and primary transplant candidates on dialysis therapy. Mortality hazard ratios (HRs) were adjusted for age, sex, race, cause of end-stage renal disease, pre-waiting list time on dialysis therapy, calendar year of wait-listing, and organ procurement organization.

RESULTS

Overall, the post-graft failure dialysis group experienced a significant 78% greater mortality (HR, 1.78; P < 0.0001) relative to the transplant candidate group. The post-graft failure dialysis/transplant candidate HR was relatively constant across age groups, but significantly greater (P < 0.0001) among patients with diabetes (HR, 1.93) than among those without diabetes (HR, 1.69). The HR was greatest during the first week after graft failure (HR, 13.6; P < 0.0001) and decreased steadily thereafter. However, despite leveling off, the HR remained significantly elevated well after graft failure, including the 5- to 10-year period after graft failure.

CONCLUSION

Based on national data, mortality among patients on dialysis therapy after primary graft failure increases significantly relative to mortality among patients still awaiting primary kidney transplantation. Additional studies are urgently needed to define the mechanism of the increased risk and strategies to decrease mortality.

Recovery of Allograft Function After Complete Withdrawal of Immunosuppression

We describe an interesting case of a patient who recovered function of a previously failed kidney allograft after immunosuppressive medications were discontinued for 4 months, requiring maintenance hemodialysis. He had a split-thickness skin graft to his abdomen because of previous surgical complications. His postoperative course was complicated by sepsis and refractory hypotension. The patient was diagnosed with adrenal insufficiency and was started on hydrocortisone. At the same time, hemodialysis was stopped for possible catheter-related infection. The patient recovered function of the previously failed allograft and has not required hemodialysis.

Renal transplant recipient outcome after losing the first graft

Renal transplantation is the optimal therapy for end-stage renal failure and considerable attention has been given to graft and patient survival and the effectiveness of immunosuppressive regimens. However, little attention has been given to outcome for patients who lose their grafts. We retrospectively reviewed the outcomes of the 793 first renal transplants performed at our institution between November 1979 and December 2001. A total of 348 patients lost their grafts, 116 by death with a functioning graft (33.3%) and 232 patients for other causes (66.7%). Eighty-six patients (37.1%) received a second transplant 3.5+/-2.4 years after returning to dialysis and the remainder continued on dialysis. Retransplanted patients were younger at the time of the first transplant (P=.000), and both time on dialysis (P=.012) and duration of graft function (P=.057) were shorter than for those remaining on dialysis. Therefore, retransplant patient survival at 1, 5, and 10 years was better than among those patients on dialysis not included on the waiting list (P<.001), but when compared with the relisted patients the survival rate was almost identical (96%, 85%, and 67% vs 97%, 82%, and 67%; P=NS). Almost 40% of patients who lost their first grafts were retransplanted. We did not observe differences in patient survival between retransplant and relisted patients. Because the number of cases is limited, our results need to be confirmed by larger series.

Death with functioning graft in living donor kidney transplantation: analysis of risk factors

BACKGROUND

Death with a functioning graft (DWF) has been reported as a major cause of graft loss after renal transplantation. It has been reported to occur in 9-30%.

METHODS

From March 1976 to January 2002, a total of 1400 living donor renal transplants were performed in our center. Out of 257 reported deaths among our patients, 131 recipients died with functioning grafts after a mean period of 53.4 +/- 53.2 months.

RESULTS

DWF patients account for 27% of all graft losses in our series. The mean age was 34.9 + 10.6 (range 8-62 years), 98 of them were male and 33 were female. The original kidney disease was GN in 9, PN in 24, PCK in 5 and nephrosclerosis in 8 patients. Acute rejection episodes were diagnosed in 84 patients (63.1). The post-transplant complications encountered were hypertension in 78 patients (59.5%), diabetes mellitus in 30 patients (22.9%), medical infections in 68 (51.5%), hepatic complications in 30 (22.9%) and malignancy in 17 patients (13%). The main causes of death in these patients were infections in 46 (35.6%), cardiovascular in 23 (17.6%), liver cell failure in 15 patients (11.4%) and malignancy in 8 (6.1%). The mean serum creatinine was 2 +/- 0.6 mg/dl at last follow-up before death.

CONCLUSION

We conclude that the relatively higher mortality in renal transplantation is, in part, due to co-morbid medical illness, pre-transplant dialysis treatment, and factors uniquely related to transplantation, including immunosuppression and other drug effects. DWF must be in consideration when calculating graft survival.