Their study showed that patients with diabetes as their PRD had slightly more than twice the risk of dying in the first 90 days after starting dialysis following graft loss as patients whose native kidney failure was caused by a diagnosis other than diabetes. Additionally, diabetes as PRD conferred an even higher risk of death between 90 days and three years.
“Identifying conditions associated with worse outcomes may help guide the management of patients with failed transplants and also identify subgroups who need more intensive monitoring,” Lynsey Webb, MD, a clinical research fellow at the U.K. Renal Registry (UKRR) at Southmead Hospital in Bristol, said at the 49th Congress of the European Renal Association-European Dialysis and Transplant Association. “Based on our findings, we believe that clinicians need to monitor patients with failing renal transplants closely and ensure timely planning for the return to dialysis and/or suitability for re-transplantation. Patients with diabetes are more susceptible to infections and therefore the commencement of dialysis via a temporary catheter due to inadequate dialysis planning may have significant consequences.”
Dr. Webb and her colleagues examined demographic and clinical data in 3,339 patients who began hemodialysis or peritoneal dialysis after failure of a first renal transplant from 2000 through 2008. Patient information was obtained from the UKRR database, and patients were followed until they died or were lost to follow-up.
Other types of PRD included glomerulonephritis, hypertension, polycystic kidney disease, pyelonephritis, renovascular disease, uncertain etiology, other high-risk diseases (such as systemic vasculitis and systemic lupus erythematosus) and other low-risk diseases (such as congenital renal hypoplasia or a traumatic kidney loss).
The increased risk of death in the diabetic PRD group is probably due to their increased co-morbidities, Dr. Webb said. “For example, diabetic patients are more likely to have cardiovascular disease and peripheral vascular disease, both of which are associated with significant morbidity and mortality.”
Poor dialysis planning may contribute to the higher mortality rate in diabetic patients, she said. Diabetics are susceptible to infection, and initiation of dialysis using a central venous catheter may be associated with a significant rate of sepsis-related complications. Instead, she recommended timely planning for the return to dialysis, with patients being considered for re-listing for further transplantation, if appropriate.
Prompt recognition of the failing transplant with regular outpatient monitoring and specialist input would allow more definitive vascular access, such as an arteriovenous fistula, to be created, thereby potentially reducing the infection risk for susceptible diabetic patients, she added.
Dr. Webb cautioned that a lack of annual comorbidity data may represent a possible study limitation. In addition, only 173 patients died in the first 90 days, a low event rate that could mean that the sample size was too small to detect a difference.