Allograft outcome following repeat transplantation of patients with non‐adherence‐related first kidney allograft failure: a population cohort study

Abstract

Nonadherence is an important risk factor for premature allograft failure after kidney transplantation, but outcomes after re-transplantation remain uncertain. Using data from the Australian and New Zealand Dialysis and Transplant registry, the associations between causes of first allograft failure and acute rejection-related and non-adherence-related allograft failure following re-transplantation were examined using competing risk analyses, treating the respective alternative causes of allograft failure and death with functioning graft as competing events. Fifty-nine of 2450 patients (2%) lost their first allografts from nonadherence. Patients who lost their first kidney allograft from nonadherence were younger at the time of first kidney allograft failure but waited longer for a second allograft (>5 years: 54% vs. 20%, P < 0.001) compared with other causes. Compared with patients who lost their first allograft from causes other than nonadherence, the adjusted subdistribution hazard ratio (HR and 95% CI) for acute rejection-related second allograft failure was 0.58 (0.08, 4.07; P = 0.582) for patients with allograft failure attributed to nonadherence and was 6.30 (1.34, 29.67; P = 0.020) for non-adherence-related second allograft failure. In this cohort of transplant recipients who have received second allografts, first allograft failure secondary to nonadherence was associated with a marginally greater risk of allograft failure attributed to nonadherence in subsequent transplantation.

Association of age with risk of first and subsequent allograft failure and mortality among young kidney transplant recipients in the USA – a retrospective cohort study

“…Due to many missing data on variables related to nonadherence, we were unable to examine the effect of nonadherence directly. Instead, we examined the association of age with time to second transplantation because patients who lost their graft from nonadherence may have a longer waiting time [22]. The result was similar to the association between age and graft failure risk.…”

“…Among 20 960 patients, 3850 (18%) patients received kidney transplants twice or more and up to five times 1638 (8) 1670 (8) 2185 102321 (11) 3778 (18) 3522 172858 (14) 2988 (14) Male (19) 186 (11) 270 (16) 375 (17) 425 (18) 720 (19) 743 (21) 609 (21) 566 (19) Other 2215 (11) 171 (10) 206 (12) 238 (11) 273 (12) 411 (11) 374 (11) 288 (10) 254 (9) Hispanic (%) 4728 (23) 287 (18) 381 (23) 478 (22) 551 (24) 915 (24) 855 (24) 636 (22) 625 (21) Medicaid (%) 140 (6) 212 9445 (12) 523 (15) 543 (19) 728 (24) FSGS 2523 1225 (2) 129 (8) 274 (13) 267 (12) 479 (13) 495 (14) 447 (16)…”

From Nonadherence to Adherence

“…The posttransplantation events in patients with a previously failed allograft can be instructive about previous rejection episodes (eg, early versus late), reason(s) of graft loss, development of DSA, graft survival time and tolerance of immunosuppressive medication including how the patients "felt, functioned and survived" (ie, patient reported outcomes). 1 A socioeconomical, cultural, educational, motivational and emotional assessment can detect potential barriers to adherence (eg, educational level, self-efficacy, financial barriers).…”

“…MNA has been associated with graft loss, (sub)clinical (late) acute T-cell-mediated rejection, allograft dysfunction, formation of de novo donor-specific anti-HLA antibodies (DSA) and humoral rejection and potentially as well with opportunistic infections like polyomavirusassociated nephropathy (PVAN). [1][2][3][4][5][6] Because MNA after SOT originates from a very diverse conglomerate of partially dynamic causes and is predominantly unintentional, simple or generic solutions are not available and therapeutic interventions require a persistent holistic individualized patient approach and a multidisciplinary support team. 7 The distinction between intentional and nonintentional MNA is not always easy because often subconscious psychological processes are involved in so-called unintentional nonadherence.…”

Retransplantation after nonadherence‐related kidney allograft failure – forgive or forget?

“…In the current issue of Transplant International, Manickavasagar et al . reported on a longitudinal cohort of kidney transplant recipients using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) who had graft failure and received a second kidney transplant . This well‐designed study allowed the authors to evaluate the risk of NA‐related second allograft failure in patients with prior graft loss because of documented nonadherence.…”