Impact of dialysis modality on survival after kidney transplant failure

Effect of End-Stage Renal Disease Prospective Payment System on Utilization of Peritoneal Dialysis in Patients with Kidney Allograft Failure

INTRODUCTION

The Center for Medicare and Medicaid Services introduced an End-Stage Renal Disease Prospective Payment System (PPS) in 2011 to increase the utilization of home dialysis modalities, including peritoneal dialysis (PD). Several studies have shown a significant increase in PD utilization after PPS implementation. However, its impact on patients with kidney allograft failure remains unknown.

METHODS

We conducted an interrupted time series analysis using data from the US Renal Data System (USRDS) that include all adult kidney transplant recipients with allograft failure who started dialysis between 2005 and 2019. We compared the PD utilization in the pre-PPS period (2005-2010) to the fully implemented post-PPS period (2014-2019) for early (within 90 days) and late (91-365 days) PD experience.

RESULTS

A total of 27,507 adult recipients with allograft failure started dialysis during the study period. There was no difference in early PD utilization between the pre-PPS and the post-PPS period in either immediate change (0.3% increase; 95% CI: -1.95%, 2.54%; p = 0.79) or rate of change over time (0.28% increase per year; 95% CI: -0.16%, 0.72%; p = 0.18). Subgroup analyses revealed a trend toward higher PD utilization post-PPS in for-profit and large-volume dialysis units. There was a significant increase in PD utilization in the post-PPS period in units with low PD experience in the pre-PPS period. Similar findings were seen for the late PD experience.

CONCLUSION

PPS did not significantly increase the overall utilization of PD in patients initiating dialysis after allograft failure.

Dialysis after kidney transplant failure: how to deal with this daunting task?

The best treatment for patients with end-stage kidney disease is kidney transplantation, which, if successful provides both a reduction in mortality and a better quality of life compared to dialysis. Although there has been significant improvement in short-term outcomes after kidney transplantation, long-term graft survival still remains insufficient. As a result, there has been an increase in the number of individuals who need dialysis again after kidney transplant failure, and increasingly contribute to kidney transplant waiting lists. Starting dialysis after graft failure is a difficult task not only for the patients, but also for the nephrologists and the care team. Furthermore, recommendations for management of dialysis after kidney graft loss are lacking. Aim of this narrative review is to provide a perspective on the role of dialysis in the management of patients with failed kidney allograft. Although numerous studies have reported higher mortality in patients undergoing dialysis following kidney allograft failure, reports are contrasting. A patient-centered, individualized approach should drive the choices of initiating dialysis, dialysis modality, maintenance of immunosuppressive drugs and vascular access.

Conservative Kidney Management in Kidney Transplant Populations

Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.

Effect of kidney replacement therapy modality after first kidney graft failure on second kidney transplantation outcomes

BACKGROUND

There is a lack of information regarding which is the best dialysis technique after kidney transplant (KT) failure. The aim of this study is to compare the effect of kidney replacement therapy modality-peritoneal dialysis (TX-PD-TX), haemodialysis (TX-HD-TX) and preemptive deceased donor retransplantation (TX-TX) on patient survival and second KT outcomes.

METHODS

A retrospective observational study from the Catalan Renal Registry was carried out. We included adult patients with failing of their first KT from 2000 to 2018.

RESULTS

Among 2045 patients, 1829 started on HD (89.4%), 168 on PD (8.2%) and 48 (2.4%) received a preemptive KT. Non-inclusion on the KT waiting list and HD were associated with worse patient survival. For patients included on the waiting list, the probability of human leucocyte antigens (HLA) sensitization and to receive a second KT was similar in HD and PD. A total of 776 patients received a second KT (38%), 656 in TX-HD-TX, 72 in TX-PD-TX and 48 in TX-TX groups. Adjusted mortality after second KT was higher in TX-HD-TX patients compared with TX-TX and TX-PD-TX groups, without differences between TX-TX and TX-PD-TX groups. Death-censored second graft survival was similar in all three groups.

CONCLUSIONS

Our results suggest that after first KT failure, PD is superior to HD in reducing mortality in candidates for a second KT without options for preemptive retransplantation.

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.

The Role of Peritoneal Dialysis in Different Phases of Kidney Transplantation

The utilization of peritoneal dialysis (PD) has been increasing in the past decade owing to various government initiatives and recognition of benefits such as better preservation of residual renal function, quality of life, and lower cost. The Advancing American Kidney Health initiative aims to increase the utilization of home therapies such as PD and kidney transplantation to treat end stage kidney disease (ESKD). A natural consequence of this development is that more patients will receive PD, and many will eventually undergo kidney transplantation. Therefore, it is important to understand the effect of pretransplant PD on posttransplant outcomes such as delayed graft function (DGF), rejection, thrombosis, graft, and patient survival. Furthermore, some of these patients may develop DGF, which raises the question of the utility of PD during DGF and its risks. Although transplant is the best renal replacement therapy option, it is not everlasting, and many transplant recipients must go on dialysis after allograft failure. Can PD be a good option for these patients? This is another critical question. Furthermore, a significant proportion of nonrenal solid organ transplant recipients develop ESKD. Is PD feasible in this group? In this review, we try to address all of these questions in the light of available evidence.

Managing Patients with Failing Kidney Allograft: Many Questions Remain

Patients who receive a kidney transplant commonly experience failure of their allograft. Transplant failure often comes with complex management decisions, such as when and how to wean immunosuppression and start the transition to a second transplant or to dialysis. These decisions are made in the context of important concerns about competing risks, including sensitization and infection. Unfortunately, the management of the failed allograft is, at present, guided by relatively poor-quality data and, as a result, practice patterns are variable and suboptimal given that patients with failed allografts experience excess morbidity and mortality compared with their transplant-naive counterparts. In this review, we summarize the management strategies through the often-precarious transition from transplant to dialysis, highlighting the paucity of data and the critical gaps in our knowledge that are necessary to inform the optimal care of the patient with a failing kidney transplant.

The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients

The return to dialysis after allograft failure is associated with increased morbidity and mortality. This transition is made more complex by the rising numbers of patients who seek repeat transplantation and therefore may have indications for remaining on low levels of immunosuppression, despite the potential increased morbidity. Management strategies vary across providers, driven by limited data on how to transition off immunosuppression as the allograft fails and a paucity of randomized controlled trials to support one approach over another. In this review, we summarize the current data available for management and care of the failing allograft. Additionally, we discuss a suggested plan for immunosuppression weaning based upon the availability of re-transplantation and residual allograft function. We propose a shared-care model in which there is improved coordination between transplant providers and general nephrologists so that immunosuppression management and preparation for renal replacement therapy and/or repeat transplantation can be conducted with the goal of improved outcomes and decreased morbidity in this vulnerable patient group.

Socioeconomic disparity, access to care and patient relevant outcomes after kidney allograft failure

Social disparity is a major impediment to optimal health outcomes after kidney transplantation. In this study, we aimed to define the association between socioeconomic status (SES) disparities and patient-relevant outcomes after kidney allograft failure. Using data from the Australia and New Zealand Dialysis and Transplant registry, we included patients with failed first kidney allografts in Australia between 2005-2017. The association between residential postcode-derived SES in quintiles (quintile 1-most disadvantaged areas, quintile 5-most advantaged areas) with uptake of home dialysis (peritoneal or home haemodialysis) within the first 12-months post-allograft failure, repeat transplantation and death on dialysis were examined using competing-risk analysis. Of 2175 patients who had experienced first allograft failure, 417(19%) and 505(23%) patients were of SES quintiles 1 and 5, respectively. Compared to patients of quintile 5, quintile 1 patients were less likely to receive repeat transplants (adjusted subdistributional hazard ratio [SHR] 0.70,95%CI 0.55-0.89) and were more likely to die on dialysis (1.37[1.04-1.81]), but there was no association with the uptake of home dialysis (1.02[0.77-1.35]). Low SES may have a negative effect on outcomes post-allograft failure and further research is required into how best to mitigate this. However, small-scale variation within SES cannot be accounted for in this study.

Dialysis after graft loss: a Swiss experience

BACKGROUND

Patients returning to dialysis after graft loss have high early morbidity and mortality.

METHODS

We used data from the Swiss Transplant Cohort Study to describe the current practice and outcomes in Switzerland. All patients who received a renal allograft between May 2008 and December 2014 were included. The patients with graft loss were divided into two groups depending on whether the graft loss occurred within 1 year after transplantation (early graft loss group) or later (late graft loss group). Patients with primary non-function who never gained graft function were excluded.

RESULTS

Seventy-seven out of 1502 patients lost their graft during follow-up, 40 within 1 year after transplantation. Eleven patients died within 30 days after allograft loss. Patient survival was 86, 81 and 74% at 30, 90 and 365 days after graft loss, respectively. About 92% started haemodialysis, 62% with definitive vascular access, which was associated with decreased mortality (hazard ratio = 0.28). At the time of graft loss, most patients were on triple immunosuppressive therapy with significant reduction after nephrectomy. One year after graft loss, 77.5% (31 of 40) of patients in the early and 43.2% (16 out of 37) in the late-loss group had undergone nephrectomy. Three years after graft loss, 36% of the patients with early and 12% with late graft loss received another allograft.

CONCLUSION

In summary, our data illustrate high mortality, and a high number of allograft nephrectomies and re-transplantations. Patients commencing haemodialysis with a catheter had significantly higher mortality than patients with definitive access. The role of immunosuppression reduction and allograft nephrectomy as interdependent factors for mortality and re-transplantation needs further evaluation.

Eligibility and patient barriers to peritoneal dialysis in patients with advanced chronic kidney disease

INTRODUCTION

The burden of chronic kidney disease (CKD) is increasing in Kenya and is a significant cause of morbidity and mortality. While definitive treatment is renal transplantation, many patients require kidney replacement therapy with haemodialysis (HD) or peritoneal dialysis (PD). The predominant modality utilized in Kenya is currently HD. There is a need to explore why PD remains underutilized and whether patient factors may be contributory to barriers that limit the uptake of PD.

METHODS

This was a descriptive cross-sectional study where patients with advanced CKD were assessed by a multidisciplinary team for PD eligibility using a standardized tool. Contraindications and barriers to the modality were recorded as was the presence or absence of support for the provision of PD. Demographic and clinical data were recorded using a standardized questionnaire. The impact of support on PD eligibility was determined.

RESULTS

We found that 68.9% patients were eligible for PD. Surgery-related abdominal scarring was the most common contraindication. Barriers to PD were identified in 45.9% and physical barriers were more common than cognitive barriers. Presence of support was associated with a significant increase in PD eligibility (p < 0.001).

CONCLUSION

The rate of eligibility for PD in this study was similar to that found in other populations. Surgical-related factors were the most commonly identified contraindication. Physical and cognitive barriers were commonly identified and may be overcome by the presence of support for PD.

Impact of dialysis modality on morbimortality of kidney transplant recipients after allograft failure. Analysis in the presence of competing events

BACKGROUND AND OBJECTIVE

The number of patients who start dialysis due to graft failure increases every day. The best dialysis modality for this type of patient is not well defined and most patients are referred to HD. The objective of our study is to evaluate the impact of the dialysis modality on morbidity and mortality in transplant patients who start dialysis after graft failure.

MATERIAL AND METHODS

A multicentre retrospective observation and cohort study was performed to compare the evolution of patients who started dialysis after graft failure from January 2000 to December 2013. One group started on PD and the other on HD. The patients were followed until the change of dialysis technique, retransplantation or death. Anthropometric data, comorbidity, estimated glomerular filtration rate (eGFR) at start of dialysis, the presence of an optimal access for dialysis, the appearance of graft intolerance and retransplantation were analyzed. We studied the causes for the first 10 hospital admissions after starting dialysis. For the statistical analysis, the presence of competitive events that hindered the observation of the event of interest, death or hospital admission was analyzed.

RESULTS

175 patients were included, 86 in DP and 89 in HD. The patients who started PD were younger, had less comorbidity and started dialysis with lower eGFR than those on HD. The mean follow-up was 34 ± 33 months, with a median of 24 months (IQR 7-50 months), Patients on HD had longer follow-up than patients on PD (35 vs. 18 months, p = < 0.001). The mortality risk factors were age sHR 1.06 (95% CI: 1.03-1.106, p = 0.000), non-optimal use of access for dialysis sHR 3.00 (95% CI: 1.507-5.982, p = 0.028) and the dialysis modality sHR (PD/HD) 0.36 (95% CI: 0.148-0.890, p = 0.028). Patients on PD had a lower risk of hospital admission sHR [DP/HD] 0.52 (95% CI: 0.369-0.743, p = < 0.001) and less probability of developing graft intolerance HR 0.307 (95% CI 0.142-0.758, p = 0.009).

CONCLUSIONS

With the limitations of a retrospective and non-randomized study, it is the first time nationwide that PD shows in terms of survival to be better than HD during the first year and a half after the kidney graft failure. The presence of a non-optimal access for dialysis was an independent and modifiable risk factor for mortality. Early referral of patients to advanced chronic kidney disease units is essential for the patient to choose the technique that best suits their circumstances and to prepare an optimal access for the start of dialysis.

Novel options for failing allograft in kidney transplanted patients to avoid or defer dialysis therapy

PURPOSE OF REVIEW

Despite improvement in short-term renal allograft survival in recent years, renal transplant recipients (RTR) have poorer long-term allograft outcomes. Allograft function slowly declines with periods of stable function similar to natural progression of chronic kidney disease in nontransplant population. Nearly all RTR transitions to failing renal allograft (FRG) period and require transition to dialysis. Conservative chronic kidney disease management before transition to end-stage renal disease is an increasingly important topic; however, there is limited data in RTR regarding how to delay dialysis initiation with conservative management.

RECENT FINDINGS

Since immunological and nonimmunological factors unique to RTR contribute to decline in allograft function, therapies to slow progression of FRG should take both sets of factors into account. Renal replacement therapy either incremental dialysis or rekidney transplantation should be explored. This required taking benefits and risks of continuing immunosuppressive medications into account when allograft nephrectomy may be necessary.

SUMMARY

FRG may benefit from various interventions to slow progression of worsening allograft function. Until there are stronger evidence to guide interventions to preserve renal function, extrapolating evidence from nontransplant patients and clinical judgment are necessary. The goal is to provide individualized care for conservative management of RTR with FRG.

Long-term outcomes after kidney transplant failure and variables related to risk of death and probability of retransplant: Results from a single-center cohort study in Brazil

Background

Returning to dialysis after kidney graft loss (GL) is associated with a high risk of mortality, mainly in the first 3–6 months. The follow-up of patients with GL should be extended to better understand crude patient outcomes, mainly in emerging countries, where the transplantation activity has increased.

Methods

This is a historical single-center cohort study conducted in an emerging country (Brazil) that included 115 transplant patients with kidney allograft failure who were followed for 44.1 (21.4; 72.6) months after GL. The outcomes were death or retransplantation after GL calculated by Kaplan-Meier and log-rank tests. Proportional hazard ratios for death and retransplantation were assessed by Cox regression.

Results

The 5-year probability of retransplantation was 38.7% (95% CI: 26.1%-51.2%) and that of death was 37.7% (95% CI: 24.9%-50.5%); OR = 1.03 (95% CI: 0.71–1.70) and P = 0.66. The likelihood of retransplantation was higher in patients who resumed dialysis with higher levels of hemoglobin (HR = 1.22; 95% CI = 1.04–1.43; P = 0.01) and lower in blood type O patients (HR = 0.48; 95% CI = 0.25–0.93; P = 0.03), which was associated with a lower frequency of retransplantation with a subsequent living-donor kidney. On the other hand, the risk of death was significantly associated with Charlson comorbidity index (HR for each point = 1.37; 95% CI 1.19–1.50; P<0.001), and residual eGFR at the time when patients had resumed to dialysis (HR for each mL = 1.14; 95% CI = 1.05–1.25; P = 0.002). The trend toward a lower risk of death when patients had resumed to dialysis using AV fistula access was observed (HR = 0.50; 95% CI 0.25–1.02; P = 0.06), while a higher risk seems to be associated with the number of previous engraftment (HR = 2.01; 95% CI 0.99–4.07; P = 0.05).

Conclusions

The 5-year probability of retransplantation was not less than that of death. Variables related to the probability of retransplantation were hemoglobin level before resuming dialysis and ABO blood type, while the risk of death was associated with comorbidities and residual eGFR.

Returning to dialysis after kidney allograft failure: the experience of the Italian Registry of Paediatric Chronic Dialysis

BACKGROUND

The need for dialysis after kidney allograft failure (DAGF) is among the top five reasons for dialysis initiation, making this an important topic in clinical nephrology. However, data are scarce on dialysis choice after transplantation and clinical outcomes for DAGF in children.

METHODS

Patients receiving chronic dialysis < 18 years were recorded from January 1991 to January 2019 by the Italian Registry of Pediatric Chronic Dialysis (IRPCD). We investigated factors influencing choice of dialysis modality, patient outcome in terms of mortality, switching dialysis modality, and kidney transplantation.

RESULTS

Among 118 patients receiving DAGF, 41 (35%) were treated with peritoneal dialysis (PD), and 77 (65%) with haemodialysis (HD). Significant predictors for treatment with PD were younger age at dialysis start (OR 0.85 per year increase [95%CI 0.72-1.00]) and PD use before kidney transplantation (OR 8.20 [95%CI 1.82-37.01]). Patients entering DAGF in more recent eras (OR 0.87 per year increase [95%CI 0.80-0.94]) and with more than one dialysis modality before kidney transplantation (OR 0.56 for being treated with PD [0.12-2.59]) were more likely to be initiated on HD. As compared to patients on HD, those treated with PD exhibited increased but non-significant mortality risk (HR 2.15 [95%CI 0.54-8.6]; p = 0.28) and higher prevalence of dialysis-related complications during DAGF (p = 0.002) CONCLUSIONS: Patients entering DAGF in more recent years are more likely to be initiated on HD. In this specific population of children, use of PD seems associated with a more complicated course. A higher resolution version of the Graphical abstract is available as Supplementary information.

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.

Management of patients with a failed kidney transplant: what should we do?

The number of kidney transplant recipients returning to dialysis after graft failure is steadily increasing over time. Patients with a failed kidney transplant have been shown to have a significant increase in mortality compared with patients with a functioning graft or patients initiating dialysis for the first time. Moreover, the risk for infectious complications, cardiovascular disease and malignancy is greater than in the dialysis population due to the frequent maintenance of low-dose immunosuppression, which is required to reduce the risk of allosensitization, particularly in patients with the prospect of retransplantation from a living donor. The management of these patients present several controversial opinions and clinical guidelines are lacking. This article aims to review the leading evidence on the main issues in the management of patients with failed transplant, including the ideal timing and modality of dialysis reinitiation, the indications for an allograft nephrectomy or the correct management of immunosuppression during graft failure. In summary, retransplantation is a feasible option that should be considered in patients with graft failure and may help to minimize the morbidity and mortality risk associated with dialysis reinitiation.

Aprender a vivir con un órgano trasplantado

Introducción: La insuficiencia Renal Crónica es una enfermedad silenciosa, cuando los síntomas aparecen la persona debe ingresar a una Terapia dialítica y/o iniciar el proceso del trasplante renal. El trasplante produce una mejoría en la calidad de vida de las personas enfermas. Objetivo: Analizar de manera comprensiva la experiencia vivida por personas con Insuficiencia Renal Crónica que han sido trasplantadas y los significados del cuidado de la salud elaborados por los familiares que interactúan con estas personas. Método: Estudio cualitativo, fenomenológico-hermenéutico, empleando el referente teórico de Van Manen, 11 personas enfermas y 5 cuidadores participaron en el estudio, en la ciudad de Neiva; información recolectada a través de entrevistas en profundidad. Resultados: Al realizar el análisis emergió el tema “la esperanza de una segunda oportunidad, aprender a vivir con un órgano trasplantado”, construido alrededor de los siguientes subtemas compartidos entre las personas enfermas y los cuidadores: la donación como un regalo de Dios, la llamada que anuncia el trasplante, reconocer la finitud del órgano y volver a nacer con el trasplante. Conclusiones: La donación es un obsequio, que se espera pacientemente en el tiempo para poner fin a un tratamiento que produce miedo y desesperación. Esta alternativa de tratamiento los lleva a volver a nacer y a recuperar la vida que han perdido por el tratamiento dialítico, aunque reconozcan que este es finito.

Transplant nephrectomy after graft failure: is it so risky? Impact on morbidity, mortality and alloimmunization

PURPOSE

To determine the impact of transplant nephrectomy on morbidity and mortality and HLA immunization.

METHODS

All patients who underwent transplant nephrectomy in our centre between 2000 and 2016 were included in this study. A total of 2822 renal transplantations and 180 transplant nephrectomies were performed during this period.

RESULTS

The indications for transplant nephrectomy were graft intolerance syndrome: 47.2%, sepsis: 22.2%, vascular thrombosis: 15.5%, tumour: 8.3% and other 6.8%. Transplant nephrectomies were performed via an intracapsular approach in 61.7% of cases. The blood transfusion rate was 50%, the morbidity rate was 38% and the mortality rate was 3%. Transplant nephrectomies more than 12 months after renal transplant failure were associated with more complications (p = 0.006). Transfusions in the context of transplant nephrectomy had no significant impact on alloimmunization.

CONCLUSION

The risk of bleeding, and therefore of transfusion, constitutes the major challenge of this surgery in patients eligible for retransplantation. Even if transfusions in this context of transplant nephrectomy had no significant impact on alloimmunization, this high-risk surgery, whenever possible, must be performed electively in a well-prepared patient.

Safety of Peritoneal Dialysis after Nonrenal Solid-Organ Transplantation

BACKGROUND

End-stage renal disease is a well-known complication after solid-organ transplantation, mostly as a result of calcineurin-inhibitor therapy. Among recipients of solid-organ transplants other than kidneys, peritoneal dialysis (PD) has been considered an accessory technique as an increased risk of infectious complications has been reported. The aim of our study was to evaluate the outcome of patients with a liver, heart, or lung transplant who underwent PD for replacement therapy.

METHODS

This was a retrospective, monocentric study. Every adult patient starting PD between January 1, 2001, and December 31, 2016, at our center was included. The history of previous solid-organ transplantation was determined. For the statistical analysis, we considered 2 groups of patients: 1 group having a history of transplantation of an organ other than the kidney (lung, heart, liver), and 1 group that was starting dialysis without any prior history of organ transplantation. Patients who had previously undergone kidney transplantation were excluded. The events of interest were the first peritonitis episode, death, and PD failure, defined as transfer to hemodialysis.

RESULTS

A total of 383 patients started PD during this period, 13 of whom had a history of organ transplantation. We found no significant difference between the solid-organ transplantation patients and those without a history of transplantation in terms of the occurrence of peritonitis (HR [hazard ratio] 0.91 [0.37 - 2.22]), death (HR 0.83 [0.26 - 2.63]), and PD failure (HR 1.01 [0.32 - 3.22]).

CONCLUSION

Peritoneal dialysis appears to be an effective replacement therapy for patients with a previous history of solid-organ transplantation.

Organ donation and transplantation in Canada: insights from the Canadian Organ Replacement Register

PURPOSE OF REVIEW

To provide an overview of the transplant component of the Canadian Organ Replacement Register (CORR).

FINDINGS

CORR is the national registry of organ failure in Canada. It has existed in some form since 1972 and currently houses data on patients with end-stage renal disease and solid organ transplants (kidney and/or non-kidney). The transplant component of CORR receives data on a voluntary basis from individual transplant centres and organ procurement organizations across the country. Coverage for transplant procedures is comprehensive and complete. Long-term outcomes are tracked based on follow-up reports from participating transplant centres. The longitudinal nature of CORR provides an opportunity to observe the trajectory of a patient's journey with organ failure over their life span. Research studies conducted using CORR data inform both practitioners and health policy makers alike.

IMPLICATIONS

The importance of registry data in monitoring and improving care for Canadian transplant candidates/recipients cannot be over-stated. This paper provides an overview of the transplant data in CORR including its history, data considerations, recent findings, new initiatives, and future directions.

Risk of death following kidney allograft failure: a systematic review and meta-analysis of cohort studies

BACKGROUND

People with kidney allograft failure represent an increasing fraction of all those starting dialysis therapy. We sought to summarize prognosis following kidney allograft failure and identify potentially beneficial interventions or modifiable risk factors.

METHODS

We searched MEDLINE and EMBASE (inception to 1 October 2013) and article reference lists without language restriction and selected cohort studies of all-cause mortality and fatal infection-related and cardiovascular events in people starting dialysis following kidney allograft failure. Two reviewers independently extracted data on study design, participant characteristics, dialysis modality, transplant nephrectomy, immunosuppression strategy, transplant-naive comparators and risk of bias. Discrepancies were resolved with a third reviewer.

RESULTS

Forty studies comprising 249 716 participants met the inclusion criteria. The first year of dialysis therapy was associated with the highest mortality. By random effects meta-analysis, annual risk of death, from years 1 to 4, was 0.12 [95% confidence interval (95% CI): 0.09-0.15], 0.06 (95% CI: 0.05-0.07), 0.05 (95% CI: 0.04-0.06) and 0.05 (95% CI: 0.04-0.06), respectively. We found high heterogeneity in each meta-analysis, which remained unexplained by prespecified subgroup analyses. We could not find sufficient information to summarize the risk for fatal infection-related and cardiovascular events, or to test the role of transplant nephrectomy or different immunosuppressive strategies. Risk of bias was high, especially participation bias.

CONCLUSION

Mortality is higher during the first year of dialysis treatment following kidney allograft failure than in subsequent years. Insufficient data are available to assess factors or interventions potentially impacting prognosis following kidney allograft failure. In a culture promoting transplantation, clinical research of different models of care in this growing high-risk population should be a research priority.

Health related quality of life in patients in dialysis after renal graft loss and effect of gender

BACKGROUND

An increasing number of dialysis patients have returned to dialysis after renal graft loss, and the transition in disease state could likely be associated with reduced health related quality of life (HRQOL). Furthermore, gender differences in HRQOL have been observed in dialysis and kidney transplanted patients, but whether transition in disease state affects HRQOL differently in respect to gender is not known. The aims of this study were to compare HRQOL in dialysis patients with graft loss to transplant naïve dialysis patients, and to explore possible gender differences.

METHODS

In a cross-sectional study, HRQOL was measured in 301 prevalent dialysis patients using the Kidney Disease and Quality of Life Short Form version 1.3. Adjusted comparisons were made between dialysis patients with previous graft loss and the transplant naïve patients. Multiple linear regression analyses were performed with HRQOL as outcome variables. Interaction analyses using product terms were performed between gender and graft loss. HRQOL was analysed separately in both genders.

RESULTS

Patients with renal graft loss (n = 50) did not experience lower HRQOL than transplant naïve patients after multiple adjustments. Among patients with graft loss, women (n = 23) reported lower HRQOL than men (n = 27) in the items physical function (40 vs. 80, p = 0.006), and effect of kidney disease (49 vs. 67, p = 0.017). Women with graft loss reported impaired kidney-specific HRQOL compared to transplant naïve women (n = 79) in the items effect of kidney disease (50 vs. 72, p = 0.002) and cognitive function (80 vs. 93, p = 0.006), and this observation persisted after multiple adjustments. Such differences were not apparent in the male counterparts.

CONCLUSIONS

Patients who resumed dialysis after renal graft loss did not have lower HRQOL than dialysis patients not previously transplanted. However, losing graft function was associated with reduced HRQOL in females, and important interactions were identified between graft loss and gender. This needs to be further explored in prospective studies.

Similar patient survival following kidney allograft failure compared with non-transplanted patients

Data from the national French Renal Epidemiology and Information Network (REIN) registry were used to compare survival between transplant recipients under age 65 who resumed dialysis after graft failure during 2007-2009 and transplant-naïve incident dialysis patients matched for age, gender, diabetes mellitus, and year of starting dialysis. Among 911 transplant patients who returned to dialysis, 103 had died by 1 January 2011. Multivariate analysis showed that age over 48 years, coronary artery disease, peripheral artery disease, and inability to walk unassisted were significant predictors of death. In the case-control analysis, the observed mortality rates in 778 transplant failure and 778 transplant-naïve dialysis patients were 11.8 and 10.8%, respectively. Kaplan-Meier estimates of survival after transplant failure vs. the transplant-naïve controls were 95.2 vs. 94.1% at 1 year, 90.3 vs. 88.8% at 2 years, and 84.2 vs. 80.2% at 3 years (log rank P=0.197 overall). Dialysis in transplant failure vs. transplant-naïve patients was not associated with significantly increased mortality. At the start of dialysis, the serum creatinine levels and the rate of unplanned dialysis were significantly lower in transplant failure patients compared with transplant-naïve controls. Thus, in patients under 65 years of age in France, survival of dialysis patients after graft loss is similar to that of incident dialysis patients who have not undergone transplantation.

Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure?

BACKGROUND

Kidney transplant failure (TF) is among the leading causes of dialysis initiation. Whether survival is similar for patients treated with peritoneal dialysis (PD) and with hemodialysis (HD) after TF is unclear and may inform decisions concerning dialysis modality selection.

METHODS

Between 1995 and 2007, 16 113 adult dialysis patients identified from the US Renal Data System initiated dialysis after TF. A multivariable Cox proportional hazards model was used to evaluate the impact of initial dialysis modality (1 865 PD, 14 248 HD) on early (1-year) and overall mortality in an intention-to-treat approach.

RESULTS

Compared with HD patients, PD patients were younger (46.1 years vs 49.4 years, p < 0.0001) with fewer comorbidities such as diabetes mellitus (23.1% vs 25.7%, p < 0.0001). After adjustment, survival among PD patients was greater within the first year after dialysis initiation [adjusted hazard ratio (AHR): 0.85; 95% confidence interval (CI): 0.74 to 0.97], but lower after 2 years (AHR: 1.15; 95% CI: 1.02 to 1.29). During the entire period of observation, survival in both groups was similar (AHR for PD compared with HD: 1.09; 95% CI: 1.0 to 1.20). In a sensitivity analysis restricted to a cohort of 1865 propensity-matched pairs of HD and PD patients, results were similar (AHR: 1.03; 95% CI: 0.93 to 1.14). Subgroups of patients with a body mass index exceeding 30 kg/m(2) [AHR: 1.26; 95% CI: 1.05 to 1.52) and with a baseline estimated glomerular filtration rate (eGFR) less than 5 mL/min/1.73 m(2) (AHR: 1.45; 95% CI: 1.05 to 1.98) experienced inferior overall survival when treated with PD.

CONCLUSIONS

Compared with HD, PD is associated with an early survival advantage, inferior late survival, and similar overall survival in patients initiating dialysis after TF. Those data suggest that increased initial use of PD among patients returning to dialysis after TF may be associated with improved outcomes, except among patients with a higher BMI and those who initiate dialysis at lower levels of eGFR. The reasons behind the inferior late survival seen in PD patients are unclear and require further study.

Timing of return to dialysis in patients with failing kidney transplants

In the last decade, the number of patients starting dialysis after a failed kidney transplant has increased substantially. These patients appear to be different from their transplant-naïve counterparts, and so may be the timing of dialysis therapy initiation. An increasing number of studies suggest that in transplant-naïve patients, later dialysis initiation is associated with better outcomes. Very few data are available on timing of dialysis reinitiation in failed transplant recipients, and they suggest that an earlier return to dialysis therapy tended to be associated with worse survival, especially among healthier and younger patients and women. Failed transplant patients may also have unique issues such as continuation of immunosuppression versus withdrawal or the need for remnant allograft nephrectomy with regard to dialysis reinitiation. These patients may have a different predialysis preparation work-up, worse blood pressure control, higher or lower serum phosphorus levels, lower serum bicarbonate concentration, and worse anemia management. The choice of dialysis modality may also represent an important question for these patients, even though there appears to be no difference in mortality between patients starting peritoneal versus hemodialysis. Finally, failed transplant patients returning to dialysis appear to have a higher mortality rate compared with transplant-naïve incident dialysis patients, especially in the first several months of dialysis therapy. In this review, we will summarize the available data related to the timing of dialysis initiation and outcomes in failed kidney transplant patients after returning to dialysis.

[Peritoneal dialysis--an ideal initial dialysis mode]

Peritoneal dialysis (PD) has become an established dialysis modality besides hemodialysis (HD). Although PD is an equal form of dialysis compared to HD, patients numbers on PD remain low worldwide. There are several reasons for this fact. The medical staff in some centers is not used to PD, so there is not enough information about the different dialysis methods available for the patients and the staff doesn't get the training that would be necessary to get familiar with PD. There are some concerns about offering PD to certain groups of patients despite excellent results as to quality of dialysis, good preservation of residual renal function, low costs compared to HD and better quality of life than on HD. However, PD should be offered to all patients requiring dialysis with very few exeptions as an ideal initial dialysis method. This includes patients with diabetes, patients with kidney transplant failure, patients with congestive heart failure and older patients.

Residual renal function in peritoneal dialysis with failed allograft and minimum immunosuppression

Immunosuppression (IS) is often withdrawn in patients with end stage renal disease secondary to a failed renal allograft, and this can lead to an accelerated loss of residual renal function (RRF). As maintenance of RRF appears to provide a survival benefit to peritoneal dialysis (PD) patients, it is not clear whether this benefit of maintaining RRF in failed allograft patients returning to PD outweigh the risks of maintaining IS. A 49 year-old Caucasian male developed progressive allograft failure nine years after living-donor renal transplantation. Hemodialysis was initiated via tunneled dialysis catheter (TDC) and IS was gradually withdrawn. Two weeks after IS withdrawal he developed a febrile illness, which necessitate removal of the TDC and conversion to PD. He was maintained on small dose of tacrolimus (1 mg/d) and prednisone (5 mg/d). Currently (1 year later) he is doing exceedingly well on cycler-assisted PD. Residual urine output ranges between 600-1200 mL/d. Total weekly Kt/V achieved 1.82. RRF remained well preserved in this patient with failed renal allograft with minimal immunosuppressive therapy. This strategy will need further study in well-defined cohorts of PD patients with failed allografts and residual RRF to determine efficacy and safety.

[Kidney nephrectomy after allograft failure]

The number of kidney-transplant patients that return to dialysis therapy after a failed kidney allograft is increasing sharply. These patients differ from patients treated with chronic dialysis, but who have never received a transplant; i.e., former transplanted patients display a higher risk of morbidity-mortality, particularly from cardiovascular and infectious complications. The management of immunosuppression has not been codified for patients with a failed kidney allograft: immunosuppressive therapy can be either abruptly stopped or progressively reduced. In addition, nephrectomy of the failed allograft is debatable. Some advocate this procedure only when there is intolerance, e.g., gross hematuria, local pain, or unexplained inflammatory syndrome. In contrast, others propose a systematic nephrectomy, mainly to reveal anti-HLA antibodies within peripheral blood that may have been adsorbed within the failed allograft, and are not detected, even using sensitive techniques. Prospective studies are warranted to answer these issues.

Old and new perspectives on peritoneal dialysis in Italy emerging from the Peritoneal Dialysis Study Group Census

BACKGROUND

To understand how peritoneal dialysis (PD) was being used in Italy in 2005 and 2008, a census of all centers was carried out.

METHODS

In 2005 and 2008, data were collected from, respectively, 222 and 223 centers, with respect to 4432 and 4094 prevalent patients.

RESULTS

In the two periods, the PD incidence remained stable (24.3% vs 22.9%), varying from center to center. Continuous ambulatory PD (CAPD) was the main initial method (55%), but APD was more widespread among prevalent patients (53%). Among patients returning to dialysis from transplantation (Tx), PD was used in 10%. The use of incremental CAPD increased significantly from 2005 to 2008, in terms both of the number of centers (27.0% vs 40.9%) and of patients (13.6% vs 25.7%). Late referrals remained stable at 28%, with less use of PD. The overall drop-out rate (episodes/100 patient-years) remained unchanged (31.0 vs 32.8), with 13.1 and 12.9 being the result of death, and 11.8 and 12.4 being the result of a switch to hemodialysis, mainly after peritonitis. A dialysis partner was required by 21.8% of the PD patients. The incidence of peritonitis was 1 episode in 36.5 and 41.1 patient-months, with negative cultures occurring in 17.1% of cases in both periods. The incidence of encapsulating peritoneal sclerosis (episodes/100 patient-years) was 0.70, representing 1.26% of patients treated. The catheter types used and the sites and methods of insertion varied widely from center to center.

CONCLUSIONS

These censuses confirm the good results of PD in Italy, and provide insight into little-known aspects such as the use of incremental PD, the presence of a dialysis partner, and the incidence of encapsulating peritoneal sclerosis.

The impact of treatment transitions between dialysis and transplantation on illness cognitions and quality of life - a prospective study

OBJECTIVES

Treatment transitions are frequent in end-stage renal disease (ESRD) but little is known about cognitive responses pre- to post-transplantation or after transplant failure. The purpose of this study was to examine changes in illness cognitions across treatment transitions between dialysis and transplantation and their impact on quality of life (QOL).

METHODS

In this longitudinal study, ESRD patients (N= 262) patients were followed up across treatment transitions over a 7-year observation window using the Illness Perceptions Questionnaire, the Illness Effects Questionnaire, and measures of QOL. Study sample comprised the patients from this cohort who switched treatment modality (N= 60 post-transplantation; N= 28 transplant failure). Data were collected while on dialysis or transplantation and at 6 months post-treatment change.

RESULTS

Significant changes in QOL and illness perceptions were found in treatment transitions with opposite patterns of either improvement or deterioration following transplantation or transplantation failure. Pre- to post-transplantation, QOL improves and patients report less symptoms, lower consequences, and illness intrusiveness, more acute timeline and stronger control beliefs (ps < .01). QOL is diminished following transplant failure and patients report more symptoms, consequences, illness disruptiveness, more chronic timeline, and lower control. Changes in cognitions are associated with changes in QOL (R(2) = .469-.789).

CONCLUSIONS

Treatment transitions marked significant changes in illness perceptions that were associated with changes in QOL. Interventions to prepare patients for treatment transitions and prevent increasingly negative patterns of illness perceptions with transplant failure may serve towards maintaining or improving adjustment outcomes.

Timing of dialysis initiation in transplant-naive and failed transplant patients

Over the past two decades, most guidelines have advocated early initiation of dialysis on the basis of studies showing improved survival in patients starting dialysis early. These recommendations led to an increase in the proportion of patients initiating dialysis with an estimated glomerular filtration rate (eGFR) >10 ml/min/1.73 m(2), from 20% in 1996 to 52% in 2008. During this period, the percentage of patients starting dialysis with an eGFR ≥15 ml/min/1.73 m(2) increased from 4% to 17%. However, recent studies have failed to substantiate a benefit of early dialysis initiation and some data have suggested worse outcomes for patients starting dialysis with a higher eGFR. Several reasons for this seemingly paradoxical observation have been suggested, including the fact that patients requiring early dialysis are likely to have more severe symptoms and comorbidities, leading to confounding by indication, as well as biological mechanisms that causally relate early dialysis therapy to adverse outcomes. Patients with a failing renal allograft who reinitiate dialysis encounter similar problems. However, unique factors associated with a failed allograft means that the optimal timing of dialysis initiation in failed transplant patients might differ from that in transplant-naive patients with chronic kidney disease. In this Review, we discuss studies of dialysis initiation and compare risks and benefits of early versus late initiation and reinitiation of dialysis therapy.

Care of the patient after renal allograft failure: managing the present and planning for the future

The number of patients with end-stage renal disease undergoing kidney transplantation - both cadaveric and living-donor - continues to rise. With long-term graft survival relatively fixed, this trend means that increasing numbers of patients are returning to dialysis after graft loss. Most will never be retransplanted, which introduces a host of clinical questions regarding optimal management of this unique patient population. In this paper, we explore data that informs astute care of the patient requiring dialysis after graft loss. We address new data about the increased clinical risk and the optimal dialysis modality in renal allograft loss, explore new approaches to immunosuppression and transfusion management, and examine the risks and benefits of allograft nephrectomy and timing thereof. While there are no randomized clinical trials in this field, rapidly evolving data will aid the clinician whose practice includes patients who have been transplanted and are returning to dialysis.

Peritoneal dialysis in transplant recipient patients: outcomes and management

Transplant recipient patients performing dialysis represent a growing population in the integrated model of renal replacement therapy. This includes both patients with kidney allograft loss and non-renal organ transplant recipients requiring dialysis. Although a number of possible advantages of peritoneal dialysis over haemodialysis could hypothetically favour its choice when starting dialysis, peritoneal dialysis penetration is relatively residual in this population. Questions about its safety and adequacy in these patients can explain this fact. The purpose of this review is to address unfounded fears and document evidence that peritoneal dialysis should be considered a viable and safe choice in patients returning to dialysis. Specific issues that still need further investigation are also discussed.