Transplant Failure Portends Higher Mortality Risk

PARIS—Patients starting dialysis after primary renal transplant failure who are waitlisted for repeat transplantation have a higher risk of dying over the first three years after graft loss than dialysis patients waitlisted for their first transplant, investigators reported at the 49th Congress of the European Renal Association-European Dialysis and Transplant Association .

Lynsey Webb, MD, a clinical research fellow at the U.K. Renal Registry at Southmead Hospital in Bristol, and co-workers determined survival after transplant failure only in patients deemed suitable for repeat transplantation.

The analysis included 1,498 patients starting hemodialysis (HD) or peritoneal dialysis (PD) after failure of a first renal transplant and who were waitlisted for repeat transplantation within two years of graft failure and 11,412 patients starting HD or PD as their initial form of renal replacement therapy (RRT) who were waitlisted for transplantation within two years of starting RRT. Patient data were obtained from the U.K. Renal Registry database from 2000-2008.

Patients with established renal failure (ERF) who undergo successful renal transplantation have improved survival and quality of life compared with patients who remain on dialysis, Dr. Webb said. Patients starting dialysis after graft failure have increased mortality compared with dialysis patients waitlisted for primary renal transplantation because patients with failed transplants have had ERF for a significantly longer period and are thus likely to have more comorbidities.

Dr. Webb emphasized that the U.K. Renal Registry does not collect annual co-morbidity data and thus cannot adjust for the effect of the accrued co-morbidity in failed transplant recipients. Thus, the analysis included only failed transplant recipients who were deemed “fit enough” to be listed for re-transplantation when comparing survival with waitlisted incident dialysis patients. Patients with failed grafts who are listed for a second transplantation are likely to have fewer comorbidities than failed transplant recipients not fit for wait listing (for example, due to cardiovascular disease, infection, or malignancy) and, therefore, are arguably a more appropriate comparator group, she said.

Results showed that in the first year following graft loss, re-listed patients were 1.6 times more likely to die than dialysis patients awaiting their first transplant. This increased risk persisted over the first three years.

“This study suggests that patients with failing transplants need to be reviewed regularly with timely planning for their return to dialysis,” Dr. Webb said.  “Careful consideration should be given to timely waitlisting for repeat transplantation, the hope being prompt waitlisting prior to dialysis commencement would minimize any time on dialysis.”

Dr. Webb acknowledged that missing co-morbidity data may represent a possible study limitation. She also said that studies are needed to examine the causes of mortality and morbidity after graft failure.

“We are planning to look at the cause of death (as recorded on official death certificates) to explore what specifically these patients die from. For example, is it cardiovascular disease or infection?  This will allow more targeted health screening and surveillance.”

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