Late Renal Transplant Failure: An Adverse Prognostic Factor at Initiation of Peritoneal Dialysis

Abstract

Background Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis. Objective To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant. Setting Peritoneal dialysis (PD) unit in a teaching hospital. Patients and Design All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998. Results There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group ( p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease. Conclusions W e conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.

Patient and technique survival on peritoneal dialysis in patients with failed renal allograft: A case–control study

“…Nevertheless, the majority of patients with a failed allograft initiate hemodialysis (HD) as their next renal replacement modality. 2 The reasons very few patients initiate PD after failed allograft may be related to the perceived uncertainty about the success of PD in this patient population because of the paucity of outcome studies [5][6][7] and concerns about an increased risk of therapy-related infections. 6,8 The increased risk of infection is assumed to be sustained after allograft failure because of continuation of immunosuppressive therapy to preserve residual allograft function.…”

Peritoneal dialysis in patients with failed kidney transplant: Single centre experience

“…This negative bias was reinforced by case reports of PD patients developing ‘unusual’ infections when concomitantly treated with immunosuppressive drugs . Moreover, the studies by Andrews et al and Sasal both suggested a trend towards higher peritonitis rates in the PD patients receiving immunosuppression. However, these studies were in an era when Y‐disconnect PD systems were being introduced (between 1989 and 1996) and peritonitis rates were considerably higher (up to 1 in 9.7 patients months) than current infection rates.…”

Clinical Outcomes after Failed Renal Transplantation—Does Dialysis Modality Matter?

“…The initial studies of patients returning to PD after graft loss were small, single‐center studies with data collection spanning several years (10,11,14,18,19). Most of these observed equivalent or better survival for PD patients returning to DAGL when compared with transplant‐naïve PD patients; they have been since confirmed by two large studies (15,16).…”

“…Sasal et al. studied 42 patients with failed renal allografts returning to PD between 1989 and 1996 compared to an incident historical cohort of 43 transplant‐naïve PD patients (18). Matched only by age and diabetes, the failed‐transplant group had worse outcomes with more technique failure and decreased survival.…”

“…Many authors have suggested that ongoing maintenance immunosuppression is not associated with an increased risk of infectious complications in patients returning to DAGL (15,16,18,45,52). In PD patients however, there is always a concern that peritonitis rates may be higher in individuals on immunosuppression.…”