Investigators have identified 2 distinct populations at high risk for graft loss after kidney transplantation. Risk factors at baseline suggest approaches to management, according to investigators.

Among 5752 solitary kidney transplants performed 2006-2018, graft loss occurred in 21.6% of patients, including 9.6% with graft failure and 12.0% with death with a functioning graft (DWFG).

The top causes of graft failure were alloimmunity (38.7%), glomerular diseases (18.6%), and renal tubular injury (13.9%), Mark D. Stegall, MD, of William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota, and colleagues reported in Transplantation Direct. More than three-quarters (79.4%) of the alloimmune losses were associated with antibody-mediated damage. Renal tubular injury comprised recurrent episodes of acute tubular necrosis due to infection (39.0%), recurrent/chronic hypovolemia (14.3%), a severe episode of acute tubular injury (16.9%), and cardiorenal syndrome (15.6%).

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Major causes of DWFG included malignancy (20.0%), infection (19.7%), and cardiac disease (12.6%) with risk factors of older age, pretransplant dialysis, and diabetes as the cause of kidney failure.

According to competing risk incidence models, patients aged 55 years and younger had significantly higher rates of graft failure due to alloimmune causes compared with older patients. Recipients with vs without diabetes had significantly higher rates of nonalloimmune graft loss. Patients with nonalloimmune causes of graft failure had fewer rejection episodes and were older and less nonadherent to therapy compared with patients with alloimmune causes.

According to Dr Stegall’s team, the data indicate that there are 2 populations of high-risk transplant recipients that can be identified at baseline: Young recipients without diabetes who lose their allograft due to alloimmunity and older recipients with diabetes prone to DWFG and graft failure due more often to a mixture of nonalloimmune causes.

“Some of the possible approaches [to prevent allograft failure] include improved management of diabetes, including bariatric surgery; calcineurin-inhibitor free immunosuppression, which has been shown to improve a combined endpoint of patient and graft survival at 7 y; and the avoidance of pretransplant dialysis via preemptive kidney transplantation,” Dr Stegall and colleagues wrote.


Merzkani MA, Bentall AJ, Smith BH, et al. Death with function and graft failure after kidney transplantation: Risk factors at baseline suggest new approaches to management. Transplantation Direct. 8(2):e1273. doi:10.1097/TXD.0000000000001273