Peritoneal dialysis in patients with failed kidney transplant: Single centre experience

Comparison of outcomes between kidney transplant-naïve and post-transplant graft failure peritoneal dialysis patients

BACKGROUND

This study was conducted to compare clinical outcomes between transplant-naïve peritoneal dialysis (PD) patients and those returning to PD after a failed allograft.

METHODS

In this retrospective cohort study during 2006 and 2016, we included a total of 786 patients on chronic PD. Of them 679 were transplant-naïve, 75 patients underwent a successful transplantation, and 32 patients returned to PD after a failed kidney allograft. Baseline demographics and clinical characteristics were analyzed in relation to the outcomes of all-cause mortality and peritonitis rate. We employed the Kaplan-Meier method and Cox proportional hazards model to evaluate survival, while Poisson regression was utilized to estimate rate ratios for peritonitis.

RESULTS

During a median follow-up of 6.37 years, 56.68 % death and 146.62 episodes of peritonitis/patient-year were observed. Compared with patients who received a kidney graft, transplant-naïve patients were older, more with diabetes and having higher mortality (58.6 ± 15.8, 40.5 % and 57.73 %, p < 0.0001). After accounting for age, gender, and comorbidities, the adjusted hazards ratios were 0.26 (95 % CI 0.13-0.53) in patients with a functioning graft and 1.12 (95 % CI 0.61-2.06) in patients returning to PD after graft failure, compared respectively with concurrent PD patients without kidney transplant. The adjusted rate ratio of peritonitis in patients resuming PD after graft failure was 0.55 (95 % CI: 0.22-1.14) compared to those without kidney transplant.

CONCLUSIONS

Patients restarting PD after graft failure exhibited clinical outcomes comparable to transplant-naïve PD patients. These findings support the feasibility of reinitiating PD after kidney transplant fails.

Risk factors for infection in patients with a failed kidney allograft on immunosuppressive medications

Patients with a failing kidney allograft are often continued on immunosuppression (IS) to preserve residual kidney function and prevent allosensitization. It has been previously accepted that maintaining patients on immunosuppressive therapy results in an increased risk of infection, hospitalization, and mortality. However, as the management of IS in patients with a failed kidney allograft continues to evolve, it is important to review the data regarding associations between infection and specific immunosuppression regimens. We present a review of the literature of failed kidney allograft management and infection risk, and discuss practices for infection prevention. Fifteen studies, published from 1995 to 2022, which investigated the experience of patients with failed allograft and infection, were identified. Infection was most commonly documented as a general event, but when specified, included infections caused by Candida, Mycobacterium tuberculosis, and Aspergillus. In addition, the definition of reduced "IS" varied from decreased doses of a triple drug regimen to monotherapy, whereas others did not specify which medications patients were receiving. Despite attempts at lowering net immunosuppression, patients with failed allografts remain at risk of acquiring opportunistic and non-opportunistic infections. Although opportunistic infections secondary to IS are expected, somewhat surprisingly, it appears that the greatest risk of infection may be related to complications of dialysis. Therefore, mitigating strategies, such as planning for an arteriovenous (AV) fistula over a hemodialysis catheter placement, may reduce infection risk. Additional studies are needed to provide more information regarding the types and timing of infection in the setting of a failed kidney allograft. In addition, more data are needed regarding specific medications, doses, and timing of taper of IS to guide future patient management and inform strategies for infection surveillance and prophylaxis.

Peritoneal dialysis after failed kidney allograft: Comparing patients with and without pd before transplant

BACKGROUND

The result of published studies on the clinical outcome of peritoneal dialysis (PD) after kidney allograft failure is conflicting. There are also few published data on the outcome of patients who had PD before kidney transplant and then return to PD after allograft failure.

METHODS

We reviewed 100 patients who were started on PD after kidney allograft failure between 2001 and 2020 (failed transplant group); 50 of them received PD before transplant. We compared the clinical outcome to 200 new PD patients matched for age, sex, and diabetic status (control group).

RESULTS

The patients were followed for 45.8 ± 40.5 months. the 2-year patient survival rate was 83.3% and 87.8% for the failed transplant and control groups, respectively (log rank test, p = 0.2). The corresponding 2-year technique survival rate 66.5% and 71.7% (p = 0.5). The failed transplant and control groups also had similar hospitalization rate and peritonitis rate. In the failed transplant group, there was also no difference in patient survival, technique survival, hospitalization, or peritonitis rate between those with and without PD before transplant. In the failed transplant group, patients who had PD before transplant and then returned to PD after allograft failure had substantial increase in D/P4 (0.585 ± 0.130 to 0.659 ± 0.111, paired t-test, p = 0.032) and MTAC creatinine (7.74 ± 3.68 to 9.73 ± 3.00 ml/min/1.73m2, p = 0.047) from the time before the transplant to the time after PD was resumed after failed allograft.

CONCLUSIONS

The clinical outcome of PD patients with a failed kidney allograft is similar to other PD patients. However, patients who have a history of PD before kidney transplant and then return to PD after allograft failure have increased peritoneal transport parameters.

Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review

Patients with a failed kidney allograft have steadily increase in recent years and returning to dialysis after graft loss is one of the most difficult transitions for chronic kidney disease patients and their assistant physicians. The management of these patients is complex and encompasses the treatment of chronic kidney disease complications, dialysis restart and access planning, immunosuppression withdrawal, graft nephrectomy, and evaluation for a potential retransplant. In recent years, several groups have focused on the management of the patient with a failing renal graft and expert recommendations are arising. A review of Pubmed, ScienceDirect and the Cochrane Library was performed focusing on the specific care of these patients, from the management of low clearance complications to concerns with a subsequent kidney transplant. Conclusion: There is a growing interest in the failing renal graft and new approaches to improve these patients' outcomes are being defined including specific multidisciplinary programs, individualized immunosuppression withdrawal schemes, and strategies to prevent HLA sensitization and increase retransplant rates.

Comparison of outcomes of peritoneal dialysis between patients after failed kidney transplant and transplant-naïve patients: a meta-analysis of observational studies

PURPOSE

The influence of prior failed kidney transplants on outcomes of peritoneal dialysis (PD) is unclear. Thus, we conducted a systematic review and meta-analysis to compare the outcomes of patients initiating PD after a failed kidney transplant with those initiating PD without a prior history of kidney transplantation.

METHODS

We searched PubMed, Embase, CENTRAL, and Google Scholar databases from inception until 25 November 2020. Our meta-analysis considered the absolute number of events of mortality, technical failures, and patients with peritonitis, and we also pooled multi-variable adjusted hazard ratios (HR).

RESULTS

We included 12 retrospective studies. For absolute number of events, our analysis indicated no statistically significant difference in technique failure [RR, 1.14; 95% CI, 0.80-1.61; I²=52%; p = 0.48], number of patients with peritonitis [RR, 1.13; 95% CI, 0.97-1.32; I²=5%; p = 0.11] and mortality [RR, 1.00; 95% CI, 0.67-1.50; I²=63%; p = 0.99] between the study groups. The pooled analysis of adjusted HRs indicated no statistically significant difference in the risk of technique failure [HR, 1.25; 95% CI, 0.88-1.78; I²=79%; p = 0.22], peritonitis [HR, 1.04; 95% CI, 0.72-1.50; I²=76%; p = 0.85] and mortality [HR, 1.24; 95% CI, 0.77-2.00; I²=66%; p = 0.38] between the study groups.

CONCLUSION

Patients with kidney transplant failure initiating PD do not have an increased risk of mortality, technique failure, or peritonitis as compared to transplant-naïve patients initiating PD. Further studies are needed to evaluate the impact of prior and ongoing immunosuppression on PD outcomes.

Peritoneal dialysis patient selection from a comorbidity perspective

Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.

Clinical outcomes of incident peritoneal dialysis patients coming from kidney transplantation program: A case-control study

Introduction

Brazil ranks second in the absolute number of transplantations in the world. Despite improvements in graft survival, many patients will progress to graft loss and return to dialysis. Concerns exist regarding adverse clinical outcomes in this population when undergone peritoneal dialysis (PD).

Objective

To compare the occurrence of mortality, technique failure, and peritonitis among incident patients in PD coming from either Tx or pre-dialysis treatment.

Methodology

A retrospective study in which 47 adult patients with Tx failure (Tx group) were matched for age, gender, diabetes mellitus (DM), modality and start year of PD, with 1:1 predialysis patient (nTx group). The Fine-Gray competing risk model was used to analyze mortality and technique failure.

Results

Compared to nTx, the Tx group had a lower body mass index, serum potassium, and albumin concentrations. A higher ferritin level, transferrin saturation and the number of patients with positive serology for viral hepatitis were also observed in the Tx group. In the multivariate analysis, patients of the Tx group had 4.4-times higher risk of death (p = 0.007), with infection as the main cause. Technique failure and peritonitis were similar in both groups.

Conclusion

Previous Tx is a risk factor for mortality but not for technique failure or peritonitis in incident patients on a PD program.