Evolving Trends in Risk Profiles and Outcomes in Older Adults Undergoing Kidney Retransplantation

Abstract

Original Clinical Science-General Background. In older adults (≥65), access to and outcomes following kidney transplantation (KT) have improved over the past 3 decades. It is unknown if there were parallel trends in re-KT. We characterized the trends, changing landscape, and outcomes of re-KT in older adults. Methods. Among the 44,149 older kidney-only recipients in the Scientific Registry of Transplant Recipients, we identified 1743 who underwent re-KT. We analyzed trends and outcomes (mortality, death-censored graft failure [DCGF]) by eras (1995-2002, 2003-2014, and 2015-2016) that were defined by changes to the expanded criteria donors and Kidney Donor Profile Index policies. Results. Among all older kidney-only recipients during 1995-2002, 2003-2014, 2015-2016 the proportion that were re-KTs increased from 2.7% to 4.2% to 5.7%, P < 0.001, respectively. Median age at re-KT (67-68-68, P = 0.04), years on dialysis after graft failure (1.4-1.5-2.2, P = 0.003), donor age (40.0-43.0-43.5, P = 0.04), proportion with panel reactive antibody 80-100 (22.0%-32.7%-48.7%, P < 0.001), and donation after circulatory death (1.1%-13.4%-19.5%, P < 0.001) have increased. Despite this, the 3-y cumulative incidence for mortality (22.3%-19.1%-11.5%, P = 0.002) and DCGF (13.3%-10.0%-5.1%, P = 0.01) decreased over time. Compared with deceased donor retransplant recipients during 1995-2002, those during 2003-2014 and 2015-2016 had lower mortality hazard (aHR = 0.78, 95% confidence interval, 0.63-0.86 and aHR = 0.55, 95% confidence interval, 0.35-0.86, respectively). These declines were noted but not significant for DCGF and in living donor re-KTs. Conclusions. In older retransplant recipients, outcomes have improved significantly over time despite higher risk profiles; yet they represent a fraction of the KTs performed. Our results support increasing access to re-KT in older adults; however, approaches to guide the selection and management in those with graft failure need to be explored. (Transplantation 2022;106: 1051-1060. work described; and approved the final version. M.A.M.-D. did research idea and study design, data analysis and interpretation; critically revised the article; provided intellectual content of critical importance to the work described; and approved the final version. D.L.S. receives speaking honoraria from Sanofi and Novartis. S.S. has received an education grant from Amgen Canada. The rest of the authors have no disclosures. The results presented in this article have not been published previously in whole or part, except in abstract format. This study was supported by the National Institutes of Health R01DK120518 (to M.A.M.-D.) and K24AI144954 (to D.L.S). M.A.M.-D. was also supported by R01AG055781 from the National Institute on Aging and R01DK114074 from National Institute of Diabetes and Digestive and Kidney Diseases. The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, writing, review, or approval o...

Age Disparities in Access to First and Repeat Kidney Transplantation

“…However, the past 2 decades have shown increasing benefits of re-KT among older adults, including decreased mortality and post-KT outcomes that are comparable with those who receive their first KT at an older age. 24 Therefore, re-KT provides the best chance for long-term survival and quality of life in patients with graft failure compared with maintenance dialysis therapy. [38][39][40] However, this reflects an important issue.…”

“…This older age cutoff arises from the fields of geriatrics/gerontology, is commonly used for clinical decision-making, [21][22][23] and is the most commonly used age cutoff for defining older adults in the field of transplantation. 1,[24][25][26] The outcomes of interest were listing for and receiving first KT in the transplant-naive dialysis cohort. In this cohort, all patients were followed from the date of first dialysis services to the date of being listed for first KT, censoring for death, receiving KT without being listed, or end of study (December 31, 2018).…”

Comparing outcomes of third and fourth kidney transplantation in older and younger patients

“…In our previous work in older adults, 32% and 18% of older adults with first KT and second KT received ECDs, respectively. 26,27 Thus, not only are a highly selected group of older adults receiving 3KT and 4KT, but even donor selection seems preferential.…”

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss

“…Retransplantation was associated with a 68% lower adjusted risk of death compared with dialysis and this benefit was observed in all subgroups examined including diabetic patients, patients older than 60 years-old, and patients with PRA > 80%. [ 3 ] The survival benefit of retransplantation has been addressed in other specific subgroups including patients with previous posttransplant lymphoproliferative disorders [ 24 ], first graft loss due to BK nephropathy [ 25 ], third or fourth kidney retransplant [ 26 ], and older recipients [ 27 , 28 ] and found similar graft and patient survival rates. Even in patients older than 70 years-old, there was a slight survival advantage in retransplantation as opposed to remaining on dialysis after first graft failure [ 29 ].…”