Influence of dialysis duration and modality on kidney transplant outcomes

Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes

BACKGROUND

This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center.

METHODS

This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders.

RESULTS

The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2-68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity.

CONCLUSIONS

SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.

Effect of Pretransplant Dialysis Method and Vintage on Early Clinical Outcomes of Kidney Transplantation

BACKGROUND

Pre-transplantation dialysis duration and modality may affect patients' long-term (mortality and graft failure) and short-term (delayed graft function) outcomes after kidney transplantation. We aimed to assess the impact of the method and duration of dialysis therapy on the graft function in the first 6 months post-transplant.

METHODS

The analysis included 122 kidney transplant patients (109 from a deceased donor and 13 from a living donor). Before transplantation, 91 were on hemodialysis (HD), 19 were on peritoneal dialysis (PD), and 9 received preemptive transplants. The incidence of delayed graft function (DGF) and creatinine levels at discharge and 6 months after transplantation were assessed.

RESULTS

PD and HD patients did not differ in age, number of mismatches, and cold ischemia time (CIT), but they had a significantly shorter dialysis vintage (18.3 ± 25.7 vs 39.6 ± 34.3 months, P = .01) and a lower incidence of DGF (5% vs 37%, P = .006). The duration of hospitalization and creatinine concentration at discharge and after 6 months were similar. Preemptively transplanted patients had a significantly shorter CIT (ND vs DO - 576 ± 362 vs 1113 ± 574, P = .01; ND vs HD - 576 ± 362 vs 1025 ± 585 minutes, P = .01). DGF did not occur in any of the patients transplanted preemptively. They had slightly shorter hospitalization times and, compared to HD, better graft function at discharge. After 6 months, creatinine levels were comparable to HD and PD. Patients dialyzed for less than 12 months, regardless of the method, had a lower incidence of DGF.

CONCLUSIONS

Peritoneal dialysis and a short duration of pre-transplant dialysis may improve the early results of kidney transplantation.

Association Between Pretransplant Dialysis Modality and Kidney Transplant Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

The benefits and disadvantages of different pretransplant dialysis modalities and their posttransplant outcomes remain unclear in contemporary kidney transplant care.

OBJECTIVE

To summarize the available evidence of the association of different pretransplant dialysis modalities, including hemodialysis and peritoneal dialysis (PD), with posttransplant outcomes.

DATA SOURCES

MEDLINE, Embase, PubMed, Cochrane Library, Scopus, CINAHL, and gray literature were searched from inception to March 18, 2022 (updated to April 1, 2022), for relevant studies and with no language restrictions.

STUDY SELECTION

Randomized clinical trials and nonrandomized observational (case-control and cohort) studies that investigated the association between pretransplant dialysis modality and posttransplant outcomes regardless of age or donor sources (living or deceased) were abstracted independently by 2 reviewers.

DATA EXTRACTION AND SYNTHESIS

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology reporting guidelines, 2 reviewers independently extracted relevant information using a standardized approach. Random-effects meta-analysis was used to estimate pooled adjusted hazard ratio (HR) or odds ratio and 95% CI.

MAIN OUTCOMES AND MEASURES

Primary outcomes included all-cause mortality, overall graft failure, death-censored graft failure, and delayed graft function. Secondary outcomes included acute rejection, graft vessel thrombosis, oliguria, de novo heart failure, and new-onset diabetes after transplant.

RESULTS

The study analyzed 26 nonrandomized studies (1 case-control and 25 cohort), including 269 715 patients (mean recipient age range, 14.5-67.0 years; reported proportions of female individuals, 29.4%-66.9%) whose outcomes associated with pretransplant hemodialysis vs pretransplant PD were compared. No significant difference, with very low certainty of evidence, was observed between pretransplant PD and all-cause mortality (13 studies; n = 221 815; HR, 0.92 [95% CI, 0.84-1.01]; P = .08) as well as death-censored graft failure (5 studies; n = 96 439; HR, 0.98 [95% CI, 0.85-1.14]; P = .81). However, pretransplant PD was associated with a lower risk for overall graft failure (10 studies; n = 209 287; HR, 0.96 [95% CI, 0.92-0.99]; P = .02; very low certainty of evidence) and delayed graft function (6 studies; n = 47 118; odds ratio, 0.73 [95% CI, 0.70-0.76]; P < .001; low certainty of evidence). Secondary outcomes were inconclusive due to few studies with available data.

CONCLUSIONS AND RELEVANCE

Results of the study suggest that pretransplant PD is a preferred dialysis modality option during the transition to kidney transplant. Future studies are warranted to address shared decision-making between health care professionals, patients, and caregivers as well as patient preferences.

Transplantation of Patients With Long Dialysis Vintage in the Current Deceased Donor Kidney Allocation System (KAS)

RATIONALE & OBJECTIVE

In 2014 the wait-time calculation for deceased donor kidney transplantation in the United States was changed from the date of first waitlisting to the date of first maintenance dialysis treatment with the aim of minimizing disparities in access to transplantation. This study examined the impact of this policy on access to transplantation, patient survival, and transplant outcomes among patients treated with maintenance dialysis for a prolonged duration before waitlisting.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Patients identified in the US Renal Data System between 2008 and 2018 aged 18-70 years and in the 95th percentile of dialysis treatment duration (≥6.5 years) before waitlisting.

EXPOSURE

Waitlisting for transplantation before versus after implementation of the policy.

OUTCOME

Time from date of waitlisting to deceased donor transplantation and death, and from date of transplantation to all cause graft loss.

ANALYTICAL APPROACH

Univariate and multivariable time to event analyses.

RESULTS

Patients waitlisted after the policy change had a higher likelihood of deceased donor transplantation (HR, 3.12 [95% CI, 2.90-3.37]) and lower risk of death (HR, 0.74 [95% CI, 0.63-0.87]). The risk of graft loss was lower in the post-kidney allocation system (KAS) cohort (HR, 0.66 [95% CI, 0.55-0.80]). The proportion of adult patients treated with dialysis ≥6.5 years who were never waitlisted for transplantation remained high (73%) and did not decrease after the policy implementation.

LIMITATIONS

Cannot determine causality in this observational study.

CONCLUSIONS

The policy change was associated with an increase in deceased donor transplantation and marked improvement in patient survival for patients waitlisted after long periods of dialysis treatment without decreasing the utility of available deceased donor kidney supply. The policy was not associated with increased waitlisting of this disadvantaged population.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient's needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

Pre-transplant maintenance dialysis duration and outcomes after kidney transplantation: A multicenter population-based cohort study

The association between pre-transplant dialysis duration and post-transplant outcomes may vary by the population and endpoints studied. We conducted a population-based cohort study using linked healthcare databases from Ontario, Canada including kidney transplant recipients (n = 4461) from 2004-2014. Our primary outcome was total graft failure (i.e., death, return to dialysis, or pre-emptive re-transplant). Secondary outcomes included death-censored graft failure, death with graft function, mortality, hospitalization for cardiovascular events, hospitalization for infection, and hospital readmission. We presented results by pre-transplant dialysis duration (pre-emptive transplant, and 0.01-1.43, 1.44-2.64, 2.65-4.25, 4.26-6.45, and 6.46-36.5 years, for quintiles 1-5). After adjusting for clinical characteristics, pre-emptive transplantation was associated with a lower rate of total graft failure (adjusted hazard ratio [aHR] 0.68, 95% CI: 0.46, 0.99), while quintile 4 was associated with a higher rate (aHR 1.31, 95% CI: 1.01, 1.71), when compared to quintile 1. There was no significant relationship between dialysis duration and death-censored graft failure, cardiovascular events, or hospital readmission. For death with graft function and mortality, quintiles 3-5 had a significantly higher aHR compared to quintile 1, while for infection, quintiles 2-5 had a higher aHR. Longer time on dialysis was associated with an increased rate of several adverse post-transplant outcomes. This article is protected by copyright. All rights reserved.

Evaluation of the learning curve of pediatric kidney transplantation anesthesia

Background/aim

Pediatric kidney transplantation (PKT) anesthesia brings some different challenges than adult kidney transplantation (KT) anesthesia and there are still no studies analyzing the role of experience on PKT outcomes. In this study, we aimed to evaluate the anesthesia learning curve in pediatric kidney transplants performed in our institution and the effect of increasing experience on renal transplantation-related data.

Materials and methods

Patients age ≤ 18 years who underwent KT were included in the study, while patients age >18 years were excluded. Patients were divided into 3 groups according to the date of transplant, as the first 10 patients in Group 1, the second 10 patients in Group 2, and the final 11 in Group 3. Groups were compared according to recorded data.

Results

Thirty-one patients were included in the study. Age, sex, and body mass index were matched between the 3 groups. The mean durations of dialysis were 75.0 ± 63.0, 22.4 ± 27.9, and 5.7 ± 4.5 months for Group 1, Group 2, and Group 3, respectively (p = 0.009). Blood loss, duration of postoperative mechanical ventilation, and length of stay in the intensive care unit (ICU) were comparable between the groups. The duration of anesthesia gradually shortened from Group 1 to Group 3 but there was no significant difference between the groups. The mean number of red blood cell (RBC) transfusion was 0.9 ± 0.7 unit in group 1. It decreased to a mean of 0.6 ± 0.7 unit for group 2, and afterward significant decrease occurred down to 0 for group 3 (p = 0.004).

Conclusion

Our results demonstrate that considering the decrease in preoperative dialysis duration and operative RBC transfusion, 20 patients may be enough for anesthesia competency. Transplantation anesthesia experience before PKT, anesthesia technique, and patient characteristics may differ between institutions. Therefore, further prospective studies with established learning curve goals, larger patient volumes, and more variables are needed to validate our results.

The probability of receiving a kidney transplantation in end-stage kidney disease patients who are treated with haemodiafiltration or haemodialysis: a pooled individual participant data from four randomised controlled trials

Background

Due to a critical shortage of available kidney grafts, most patients with Stage 5 Chronic Kidney Disease (CKD5) require bridging dialysis support. It remains unclear whether treatment by different dialysis modalities changes the selection and/or preparation of a potential transplant candidate. Therefore, we assessed whether the likelihood of receiving kidney transplant (both living or deceased kidney donors) differs between haemodialysis (HD) and online haemodiafiltration (HDF) in patients with CKD5D.

Methods

Individual participant data from four randomised controlled trials comparing online HDF with HD were used. Information on kidney transplant was obtained during follow-up. The likelihood of receiving a kidney transplant was compared between HD and HDF, and evaluated across different subgroups: age, sex, diabetes, history of cardiovascular disease, albumin, dialysis vintage, fistula, and level of convection volume standardized to body surface area. Hazard ratios (HRs), with corresponding 95% confidence intervals (95% CI), comparing the effect of online HDF versus HD on the likelihood of receiving a kidney transplant, were estimated using Cox proportional hazards models with a random effect for study.

Results

After a median follow-up of 2.5 years (Q1 to Q3: 1.9–3.0), 331 of the 1620 (20.4%) patients with CKD5D received a kidney transplant. This concerned 22% (n = 179) of patients who were treated with online HDF compared with 19% (n = 152) of patients who were treated with HD. No differences in the likelihood of undergoing a kidney transplant were found between the two dialysis modalities in both the crude analyse (HR: 1.07, 95% CI: 0.86–1.33) and adjusted analysis for age, sex, diabetes, cardiovascular history, albumin, and creatinine (HR: 1.15, 95%-CI: 0.92–1.44). There was no evidence for a differential effect across subgroups based on patient- and disease-characteristics nor in different categories of convection volumes.

Conclusions

Treatment with HD and HDF does not affect the selection and/or preparation of CKD5D patients for kidney transplant given that the likelihood of receiving a kidney transplant does not differ between the dialysis modalities. These finding persisted across a variety of subgroups differing in patient and disease characteristics and is not affected by the level of convection volume delivered during HDF treatment sessions.

Influence of dialysis duration on outcomes of simultaneous pancreas-kidney transplant

OBJECTIVE

The objective of this study was to assess how pre-transplant dialysis duration affects transplant outcomes after simultaneous pancreas-kidney transplant (SPK) in patients with type 1 diabetes mellitus (T1DM).

METHODS

Data of 6887 T1DM patients who underwent SPK transplantation between 2008 and 2018 were obtained from the Scientific Registry of Transplant Recipients database. According to pre-transplant dialysis duration, the patients were divided into the preemptive SPK, 0-2 years, 2-5 years, and >5 years dialysis groups. Kaplan-Meier survival analysis was performed to compare patient and graft survival among the groups. Univariate and multivariate Cox regression analyses were used to identify predictors of transplant outcomes.

RESULTS

The mean follow-up period was 56.7 ± 34.7 months. Compared with no dialysis or preemptive SPK, dialysis for 0-2 years was not significantly associated with patient or kidney graft survival, while long-term dialysis of 2-5 years and >5 years was significantly associated with increased risk of death and kidney graft failure. However, the duration of dialysis was not associated with pancreas graft survival.

CONCLUSION

Long-term dialysis duration before SPK transplant is an independent predictor of patient death and kidney graft failure in T1DM patients.

Long-term Results of Kidney Transplantation: Analysis of Selected Factors

BACKGROUND

Kidney transplantation is considered the most effective method of treating patients with end-stage renal disease. Despite continuous improvement of short-term outcomes, progression of long-term results is minimal.

METHODS

The retrospective cohort study included 45 patients (24 women and 21 men). Terms of qualification for the study were time after kidney transplantation: minimum 25 years and satisfactory graft function. Medical documentation was analyzed from which specific laboratory parameters, information about transplantation procedure, and clinical data were selected.

RESULTS

The average time since transplantation in the study group was 30 years. Chronic glomerulonephritis was a major cause that led to end-stage renal disease among the study group. The average age of the respondents was 62 years ± 8.5 years. The average time patients had hemodialysis procedures lasted 30 months. Current estimated glomerular filtration rate (eGFR) concentration was correlated with level of creatinine measured 10 years after transplantation and current hemoglobin level (r = 0.447, P = .003, r = 0.586 P < .001). No statistically significant differences were noted in the eGFR level, depending on the current age of recipients (t = 0.511, P = .612), total ischemia time (Z = 0.334, P = .729), or hemodialysis duration (t = -1.944, P = .058).

CONCLUSIONS

The presented study emphasizes the impact of graft function on hemoglobin level and the predictive role of the creatinine measured 10 years after transplantation for long-term renal outcomes. Continuing research will enrich the knowledge about long-term care and treatment for patients after kidney transplantation.

Pretransplant NT-proBNP, Dialysis Vintage, and Posttransplant Mortality in Kidney Transplant Recipients

BACKGROUND

End-stage kidney disease and dialysis vintage are characterized by accelerated atherosclerosis, volume overload, and progressive left ventricular hypertrophy, leading to elevated N-terminal probrain natriuretic peptide (NT-proBNP) levels. Pretransplant dialysis vintage is associated with excess mortality after transplantation. We want to study whether pretransplant NT-proBNP is associated with posttransplantation mortality and if it explains the association of dialysis vintage with posttransplantation mortality in kidney transplant recipients (KTR).

METHODS

We measured plasma NT-proBNP on arrival at the hospital before kidney transplantation in 658 KTR between January 1995 and December 2005 in our center. Multivariable Cox regression analyses, adjusted for potential confounders, were used to prospectively study the associations of dialysis vintage and NT-proBNP with all-cause mortality.

RESULTS

During median 12.7 (7.8-15.6) years of follow-up after transplantation, 248 (37.7%) KTR died. Dialysis vintage was associated with an increased risk of posttransplant mortality in the fully adjusted model (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.03-1.43; P = 0.02), independent of potential confounders. The association weakened materially and lost significance after further adjustment for NT-proBNP (HR, 1.14; 0.96-1.34; P = 0.14). NT-proBNP was independently associated with all-cause mortality in the fully adjusted model (HR, 1.34; 1.16-1.55; P < 0.001). The association remained independent of adjustment for dialysis vintage (HR, 1.31; 1.13-1.52; P < 0.001).

CONCLUSIONS

Our study shows that longer dialysis vintage is associated with a higher mortality risk in KTR, and this association might be explained for a considerable part by variation in pretransplant NT-proBNP at the time of transplantation.

Choice of dialysis modality prior to kidney transplantation: Does it matter?

The population of patients with end stage renal disease (ESRD) is increasing, lengthening waiting lists for kidney transplantation. Majority of the patients are not able to receive a kidney transplant in timely manner even though it is well established that patient survival and quality of life after kidney transplantation is far better when compared to being on dialysis. A large number of patients who desire a kidney transplant ultimately end up needing some form of dialysis therapy. Most of incident ESRD patients choose hemodialysis (HD) over peritoneal dialysis (PD) as the modality of choice in the United States, even though studies have favored PD as a better choice of pre-transplant dialysis modality than HD. PD is largely underutilized in the United States due to variety of reasons. As a part of the decision making process, patients are often educated how the choice regarding modality of dialysis would fit into their life but it is not clear and not usually discussed, how it can affect eventual kidney transplantation in the future. In this article we would like to discuss ESRD demographics and outcomes, modality of dialysis and kidney transplant related events. We have summarized the data comparing PD and HD as the modality of dialysis and its impact on allograft and recipient outcomes after kidney transplantation.

Characterization of Potentially Unsafe Ambulatory Antibiotic Use and Associated Outcomes in an Adult Kidney Transplant Population

BACKGROUND

Antibiotics are frequently prescribed to kidney transplant (KTX) recipients in the outpatient setting, but there are limited data assessing the safety and outcomes associated with this practice.

OBJECTIVE

The primary objective of this study was to describe ambulatory antibiotic prescribing in a large cohort of adult KTX recipients. The secondary objective was to assess the outcomes associated with potentially unsafe antibiotic use in this population.

METHODS

National Veterans Health Administration data compiled between 2001 and 2010 were used to conduct a pharmacovigilance assessment of antibiotic prescribing, excluding intravenous agents, antifungals, antivirals, and prophylactic regimens. Multivariable Cox proportional hazard regression was used to determine the impact of safe and potentially unsafe antibiotic use on time to event for graft loss.

RESULTS

Among 5130 KTX recipients and 30 127 patient-years of follow-up, 14 259 antibiotic courses were prescribed at a rate of 0.47 courses per patient-year. Transplant or nephrology providers prescribed 24.8% of courses. Overall, 608 courses (4.3%) in 311 patients (6.1%) were considered potentially unsafe for dosages in disagreement with recommended adjustments for renal function, interaction with immunosuppressive regimens, and other pertinent safety concerns. After adjusting for baseline characteristics, unsafe antibiotic use was associated with a 40% higher risk of graft loss (adjusted hazard ratio = 1.40; 95% CI = 1.03-1.89; P = 0.030) compared with safe use.

CONCLUSIONS AND RELEVANCE

Although unsafe antibiotic prescribing was uncommon, it was associated with increased risk of graft loss. Prospective research is needed to elucidate whether the driver of poor outcomes is the safety of the antibiotic prescription or fragmented care.

Impact of pre-transplant time on dialysis on survival in patients with lupus nephritis

Lupus nephritis (LN) is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE) often leading to end-stage renal failure (ESRF) and necessitating renal transplantation (rTp). Optimal timing of rTp in SLE patients with ESRF is uncertain and could potentially affect survival. We investigated the time spent on dialysis before rTp and survival following rTp in a cohort of SLE patients. Retrospective analysis of all adult SLE patients receiving rTp over a 40-year period (1975–2015) in two tertiary UK centres. Cox proportional hazard regression and receiver operator curves (ROC) were used to determine the risk associated with time on dialysis before rTp and other potential predictors. Forty patients (age 35 ± 11 years, 34 female, 15 Caucasian, 15 Afro–Caribbean and 10 South Asian) underwent rTp. During a median follow-up of 104 months (IQR 80,145), eight (20%) patients died and the 5-year survival was 95%. Univariate analysis identified time on dialysis prior to rTp as the only potentially modifiable risk predictor of survival with a hazard ratio of 1.013 for each additional month spent on dialysis (95% CI = 1.001–1.026, p = 0.03). ROC curves demonstrated that > 24 months on dialysis had an adverse effect with sensitivity of 0.875 and specificity 0.500 for death. No other modifiable predictors were significantly associated with mortality, indicating that time on dialysis had an independent effect. Increased time on dialysis pre-transplantation is an independent modifiable risk factor of mortality in this cohort of patients with lupus nephritis.

Paired Analysis of Outcomes After Kidney Transplantation in Peritoneal and Hemodialysis Patients

BACKGROUND

The impact of dialysis modality before kidney transplantation (hemodialysis or peritoneal dialysis) on outcomes is not clear. In this study we retrospectively analyzed the impact of dialysis modality on posttransplant follow-up.

METHODS

To minimize donor bias, a paired kidney analysis was applied. One hundred thirty-three pairs of peritoneal dialysis (PD) and hemodialysis (HD) patients were transplanted at our center between 1994 and 2016. Those who received kidneys from the same donor were included in the study. HD patients were significantly older (44 vs 48 years), but the Charlson Comorbidity Index was similar (3.12 vs 3.46) in both groups. The groups did not differ significantly with respect to immunosuppressive protocols and number of mismatches (2.96 vs 2.95).

RESULTS

One-year patient (98% vs 96%) and graft (90% vs 93%) survival was similar in the PD and HD patient groups. The Kaplan-Meier curves of the patients and graft survival did not differ significantly. Delayed graft function (DGF) and acute rejection (AR) occurred significantly more often in the HD recipients. Graft vessel thrombosis resulting in graft loss occurred in 9 PD (6.7%) and 4 HD (3%) patients (P > .05). Serum creatinine concentration and estimated glomerular filtration rate (using the Modification of Diet in Renal Disease guidelines) showed no difference at 1 month, 1 year, and at final visit. On multivariate analysis, factors significantly associated with graft loss were graft vessel thrombosis, DGF, and graft function 1 month after transplantation. On univariate analysis, age, coronary heart disease, and graft loss were associated with death. Among these factors, only coronary heart disease (model 1) and graft loss were significant predictors of death on multivariate analysis.

CONCLUSION

The long-term outcome for renal transplantation is similar in patients with PD and HD. These groups differ in some aspects, however, such as susceptibility to vascular thrombosis in PD patients, and to DGF and AR in HD patients.

Outcomes of Kidney Recipients According to Mode of Pretransplantation Renal Replacement Therapy

The effects of pretransplantation dialysis modality on graft function are key issues in end-stage renal disease patients. The aim of this study was to evaluate post-transplantation outcomes according to pretransplantation renal replacement therapy modality in deceased-donor kidney transplantation. Among 444 deceased-donor kidney transplant recipients in Severance Hospital between April 1993 and Dec 2014, 275 who maintained a unique dialysis modality (hemodialysis [HD; n = 178] or peritoneal dialysis [PD; n = 97]) until transplantation were enrolled. There were no significant differences in sex, age, human leukocyte antigen mismatch, cold ischemic time, or duration of dialysis between groups. There was also no difference in 5-year graft survival between HD and PD groups (87.7% vs. 82.3%, respectively; P = .148). On multivariate Cox regression for risk factors affecting graft survival, renal replacement therapy modality was not found to be a risk factor. However, the rate of delayed graft function was higher in the HD group than in the PD group (32.0% vs. 19.6%, respectively; P = .028). In addition, graft function at 1 week after transplantation in the PD group was superior to that in the HD group. The pretransplantation dialysis modality was found to affect both delayed graft function and early graft function, although not graft survival.

Outcomes in the highest panel reactive antibody recipients of deceased donor kidneys under the new kidney allocation system

Since the institution of the new kidney allocation system in December 2014, kidney transplant candidates with the highest calculated panel reactive antibodies (cPRA) of 99-100 have been transplanted at much higher rates. However, concerns have been raised that outcomes in these patients might be impaired due to higher immunological risk and longer cold ischemia times resulting from long-distance sharing of kidneys. Here, we compare outcomes at the University of Wisconsin between study patients with cPRA 99-100 and all other recipients of deceased donor kidneys transplanted between 12/04/2014 and 12/31/2015. All patients had at least 6 months post-transplant follow-up. The mean follow-up was 13.9±3 months in cPRA ≥99% and 12.3±3.5 months in cPRA ≤98%. There was a total of 152 transplants, 25 study patients, and 127 controls. No statistically significant differences were found between the two groups in delayed graft function, rejection, kidney function, graft and patient survival, or infections. We conclude that transplanting the most highly sensitized patients with kidneys shared outside their local donation service areas is associated with excellent short-term outcomes that are comparable to controls.

Association of Pre-Transplant Dialysis Modality and Post-Transplant Outcomes: A Meta-Analysis

♦ BACKGROUND: It remains unclear whether post-transplant outcomes differ according to the pre-transplant dialysis modality (peritoneal dialysis [PD] versus hemodialysis [HD]). We performed a meta-analysis of studies that assessed either post-transplant mortality, graft survival, or delayed graft function (DGF) in both PD and HD patients. ♦ METHODS: Two independent authors searched English-language literature from January 1, 1980, through August 31, 2014, national conference proceedings, and reference lists. We used combinations of terms related to dialysis (hemodialysis, peritoneal dialysis, or renal replacement therapy), kidney transplant, and outcomes. Studies were included if they measured any of the 3 post-transplant study outcomes in both pre-transplant HD and PD. ♦ RESULTS: A total of 16 studies were included in the final analysis. Of these, 6 studies reported adjusted hazard ratio for mortality, pooled adjusted risk ratio: 0.89 (95% confidence interval [CI] 0.82 - 0.97) in favor of PD (p = 0.006). The same 6 studies reported adjusted hazard ratio for graft survival, pooled adjusted risk ratio: 0.97 (95% CI 0.92 - 1.01, p = 0.16). A total of 13 studies reported unadjusted DGF. Pooled odds ratio: 0.5 (95% CI 0.41 - 0.63) in favor of PD (p < 0.005). Significant heterogeneity observed for all outcomes: I2 = 72.7%, I2 = 59.9%, and I2 = 66.8%, respectively. ♦ CONCLUSIONS: Based on these results, pre-transplant PD is associated with better post-transplant survival than HD. Pre-transplant PD was also associated with decreased risk for DGF compared with HD, although these results were unadjusted. There was no significant difference in graft survival between pre-transplant HD and PD. These results suggest that PD may be the preferred dialysis modality for patients expected to receive a transplant.

Pre-transplant dialysis modality does not influence short- or long-term outcome in kidney transplant recipients: analysis of paired kidneys from the same deceased donor

Previous studies have reported contradictory results regarding the effect of pre-transplant dialysis modality on the outcomes after kidney transplantation (KT). To minimize the confounding effect of donor-related variables, we performed a donor-matched retrospective comparison of 160 patients that received only one modality of pre-transplant dialysis (peritoneal dialysis [PD] and hemodialysis [HD] in 80 patients each) and that subsequently underwent KT at our center between January 1990 and December 2007. Cox regression models were used to evaluate the association between pre-transplant dialysis modality and primary study outcomes (death-censored graft survival and patient survival). To control for imbalances in recipient-related baseline characteristics, we performed additional adjustments for the propensity score (PS) for receiving pre-transplant PD (versus HD). There were no significant differences according to pre-transplant dialysis modality in death-censored graft survival (PS-adjusted hazard ratio [aHR]: 0.65; 95% confidence interval [95% CI]: 0.25-1.68) or patient survival (aHR: 0.58; 95% CI: 0.13-2.68). There were no differences in 10-year graft function or in the incidence of post-transplant complications either, except for a higher risk of lymphocele in patients undergoing PD (odds ratio: 4.31; 95% CI: 1.15-16.21). In conclusion, pre-transplant dialysis modality in KT recipients does not impact short- or long-term graft outcomes or patient survival.

Depression, Anxiety, Resilience and Coping Pre and Post Kidney Transplantation - Initial Findings from the Psychiatric Impairments in Kidney Transplantation (PI-KT)-Study

PURPOSE

Depression/anxiety, impaired Health-Related Quality of Life (HRQoL) and coping and resilience structures, are associated with increased mortality/poor outcome in chronic kidney disease (CKD) patients before (CKD/pre-KT) and after kidney (CKD-T) transplantation. Less is known about prevalence rates of psychiatric symptoms and impaired HRQoL of non-transplanted compared with transplanted patients.

METHODS

In a cross-sectional study comparing 101 CKD/pre-KT patients with 151 cadaveric-transplanted (CKD-T) patients, we examined prevalence of depression/anxiety (HADS questionnaire) and coping, resilience and HRQoL (SF-12, Resilience-Scale and FKV-questionnaire).

RESULTS

The prevalence of both depressive and anxiety symptoms was not significantly different between different pre-/and CKD-T patient groups. In CKD-T no significant relations of coping strategies with kidney function were identified. Furthermore, the Resilience Scales for acceptance and competence did not suggest any differences between the CKD/pre-KT and CKD-T subgroup. In the CKD/pre-KT patients, significant correlations were identified between the acceptance subscale and partnership, as well as between the competence subscale and older age/partnership.

CONCLUSIONS

Both the CKD/pre-KT and CKD-T patients exhibited notable impairments in the HRQoL which which showed a comparable pattern of results. KT itself does not appear to be the main risk factor for the development of mental impairments.

A time-to-event model for acute rejections in paediatric renal transplant recipients treated with ciclosporin A

AIMS

Ciclosporin A (CsA) dosing in immunosuppression after paediatric kidney transplantation remains challenging, and appropriate target CsA exposures (AUCs) are controversial. This study aimed to develop a time-to-first-acute rejection (AR) model and to explore predictive factors for therapy outcome.

METHODS

Patient records at the Children's Hospital in Helsinki, Finland, were analysed. A parametric survival model in NONMEM was used to describe the time to first AR. The influences of AUC and other covariates were explored using stepwise covariate modelling, bootstrap-stepwise covariate modelling and cross-validated stepwise covariate modelling. The clinical relevance of the effects was assessed with the time at which 90% of the patients were AR free (t90).

RESULTS

Data from 87 patients (0.7-19.8 years old, 54 experiencing an AR) were analysed. The baseline hazard was described with a function changing in steps over time. No statistically significant covariate effects were identified, a finding substantiated by all methods used. Thus, within the observed AUC range (90% interval 1.13-8.40 h mg l⁻¹), a rise in AUC was not found to increase protection from AR. Dialysis time, sex and baseline weight were potential covariates, but the predicted clinical relevance of their effects was low. For the strongest covariate, dialysis time, median t90 was 5.8 days (90% confidence interval 5.1-6.8) for long dialysis times (90th percentile) and 7.4 days (6.4-11.7) for short dialysis times (10th percentile).

CONCLUSIONS

A survival model with discrete time-varying hazards described the data. Within the observed range, AUC was not identified as a covariate. This feedback on clinical practice may help to avoid unnecessarily high CsA dosing in children.

Association between pre-transplant dialysis modality and patient and graft survival after kidney transplantation

BACKGROUND

Previous studies have found inconsistent associations between pre-transplant dialysis modality and subsequent post-transplant survival. We aimed to examine this relationship using the instrumental variable method and to compare the results with standard Cox regression.

METHODS

We included 29 088 patients (age >20 years) from 16 European national or regional renal registries who received a first kidney transplant between 1 January 1999 and 31 December 2008 and were on dialysis before transplantation for a period between 90 days and 10 years. Standard multivariable Cox regression examined the association of individually assigned pre-transplant dialysis modality with post-transplant patient and graft survival. To decrease confounding-by-indication through unmeasured factors, we applied the instrumental variable method that used the case-mix adjusted centre percentage of peritoneal dialysis (PD) as predictor variable.

RESULTS

Standard analyses adjusted for age, sex, primary renal disease, donor type, duration of dialysis, year of transplantation and country suggested that PD before transplantation was associated with better patient [hazard ratio, HR (95% CI) = 0.83 (0.76-0.91)] and graft survival (HR (95% CI) 0.90 (0.84-0.96)) when compared with haemodialysis (HD). In contrast, the instrumental variable analysis showed that a 10% increase in the case-mix adjusted centre percentage of patients on PD was neither associated with post-transplant patient survival [HR (95% CI = 1.00 (0.97-1.04)] nor with graft survival [HR (95% CI) = 1.01 (0.98-1.04)].

CONCLUSIONS

The instrumental variable method failed to confirm the associations found in standard Cox regression between pre-transplant dialysis modality and patient and graft survival after transplantation. The lack of association in instrumental variable analysis may be due to better control of residual confounding.

Dialysis modality and outcomes in kidney transplant recipients

BACKGROUND AND OBJECTIVES

The influence of pretransplant dialysis modality on post-transplant outcomes is not clear. This study examined associations of pretransplant dialysis modality with post-transplant outcomes in a large national cohort of kidney transplant recipients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Linking the 5-year patient data of a large dialysis organization to the Scientific Registry of Transplant Recipients, 12,416 hemodialysis and 2092 peritoneal dialysis patients who underwent first kidney transplantation were identified. Mortality or graft failure and delayed graft function risks were estimated by Cox regression (hazard ratio) and logistic regression (odds ratio), respectively.

RESULTS

Recipients treated with peritoneal dialysis pretransplantation had lower (21.9/1000 patient-years [95% confidence interval: 18.1-26.5]) crude all-cause mortality rate than those recipients treated with hemodialysis (32.8/1000 patient-years [30.8-35.0]). Pretransplant peritoneal dialysis use was associated with 43% lower adjusted all-cause and 66% lower cardiovascular death. Furthermore, pretransplant peritoneal dialysis use was associated with 17% and 36% lower unadjusted death-censored graft failure and delayed graft function risk, respectively. However, after additional adjustment for relevant covariates, pretransplant peritoneal dialysis modality was not a significant predictor of death-censored graft failure delayed graft function, respectively. Similar trends were noted on analyses using a propensity score matched cohort of 2092 pairs of patients.

CONCLUSIONS

Compared with hemodialysis, patients treated with peritoneal dialysis before transplantation had lower mortality but similar graft loss or delayed graft function. Confounding by residual selection bias cannot be ruled out.

Graft survival rate of renal transplantation: a single center experience, (1999-2009)

BACKGROUND

Renal transplantation is the best option for treatment of the end-stage renal diseases and has more advantages than dialysis. The objective of this study is to determine the ten-year graft survival rate of renal transplantation and its associated factors in patients who have been transplanted from March 1999 to March 2009 in Nemazee Hospital Transplantation Center.

METHODS

This is a historical cohort study of 1356 renal transplantation carried out during 1999 to 2009. Kaplan-Meier method was used to determine the survival rate, log rank test to compare survival curves, and Cox regression model to determine hazard ratios and for modeling of variables affecting survival.

RESULTS

The 1, 3, 5, 7 and 10 years graft survival rates were 96.6, 93.7, 88.9, 87.1 and 85.5 percent, respectively.Cox regression model revealed that the donor source and creatinine level at discharge were effective factors in graft survival rate in renal transplantation.

CONCLUSION

Our study showed that 10 year graft survival rate for renal transplantation in Nemazee Hospital Transplantation Center was 85.5% and graft survival rate was significantly related to recipients and donor's age,donor source and creatinine level at discharge. Our experience in renal transplantation survival rate indicates asuccess rate comparable to those noted in other reports.

Plasma and urine leukocyte elastase-alpha1protease inhibitor complex as a marker of early and long-term kidney graft function

BACKGROUND

Neutrophils are mediators of ischaemia/reperfusion (I/R) injury following kidney transplantation (kTx). Leukocyte elastase (LE) complex with alpha(1)protease inhibitor (LE-alpha(1)PI) is a marker of neutrophil degranulation. The aim of this study was to evaluate LE-alpha(1)PI as a marker of I/R kidney damage and to search for correlations between leukocyte activation and post-transplant complications.

METHODS

Plasma and urine LE-alpha(1)PI were estimated in 55 deceased-donor kidney graft recipients on postoperative days (POD) 1, 3 and 7, as well as in the late post-transplant period.

RESULTS

The plasma LE-alpha(1)PI level peaked on POD 1 after kTx, and the urine LE-alpha(1)PI peaked on POD 3. On POD 1 and POD 3, the urine LE-alpha(1)PI levels were higher in delayed graft function (DGF) patients than in patients with immediate graft function (IGF: P < 0.001 and P < 0.003, respectively). Urine LE-alpha(1)PI excretion on POD 1 was significantly higher in patients with longer cold ischaemia time (CIT) than in patients with shorter CIT, P < 0.002. Multivariate regression model revealed two factors influencing the occurrence of early acute rejection-urine LE-alpha(1)PI complex on POD 3 and human leukocyte antigen (HLA) mismatches. There was a significant association between the plasma LE-alpha(1)PI on POD 3 and serum creatinine level 6 and 12 months after kTx (r(2) 0.24; P < 0.005 and 0.19; P < 0.005, respectively).

CONCLUSIONS

This study is the first presentation of a simple, non-invasive measurement of neutrophil activation after kTx. It also demonstrates a strong correlation between the early post-transplant LE-alpha(1)PI complex level and kidney graft function.