Length of time on dialysis prior to renal transplantation is a critical factor affecting patient survival after allografting

Abstract

Within the past year at our transplant center we have had the experience of performing renal allografts in two patients older than 65 years, each of whom had been on hemodialysis more than 10 years. Both resulted in patient mortality within 90 days of transplant (one due to myocardial infarction, the other due to visceral ischemia with infarction). This prompted us to review retrospectively our own data (n = 204) and the national (UNOS) data (n = 10 971) regarding transplant outcome, patient age, and length of time on dialysis prior to renal transplantation. This review revealed that patient mortality after transplant increased with the length of end-stage renal disease (dialysis, regardless of type) independent of age, the greatest mortality occurring within the first 6 months of transplant (and not thereafter); graft survival was similar for all age cohorts analyzed. Our review of the literature reveals a paucity of articles pertaining to posttransplant mortality and length of time on dialysis prior to transplant. Our results indicate the following possible conclusions. (1) The length of time of end-stage renal disease therapy prior to renal transplantation is a significant and independent risk factor for post-transplant mortality.(2) Higher priority should be given to this factor when formulating strategies for allocation of scarce resources. (3) Patients on dialysis for extended periods of time who arc elderly may be at particularly high risk. (4) Patients being considered for renal transplant should be informed of their individual risk factors for mortality post-transplant based on length of ESRD therapy. (5) Renal transplantation should be considered as early as possible in patients with ESRD (or imminent ESRD).Within the past year, we have experienced several deaths of renal transplant recipients, each of whom had been on Offprint requests to: hemodialysis for extended periods of time prior to transplantation. This prompted us to review retrospectively our own data (n = 204) and the UNOS data (n = 10 971) regarding the effect of length of end-stage renal disease (ESRD) prior to transplantation on patient survival following allografting.Many factors have been suggested to affect survival following renal transplantation, including recipient age, donor source (cadaver, LRD unrelated) and age, HLA matching, immunosuppressive regimen, and various other pretransplant conditions (e.g. cardiac status, presence or absence of diabetes mellitus, PRA, prior transplant, etc.). To our knowledge, length of time of ESRD prior to transplantation and its impact on patient survival have neither been previously emphasized nor systematically examined. Materials and methods

Allograft and Overall Survival of Patients with Posttransplant Skin Cancer

“…Other variables in kidney transplant recipients that had significantly higher risk of allograft failure and death within 5 years ( p <.05) are listed in Table 2. Many of these variables have been reported previously 13–17 . Immunosuppression at discharge (TAC and AZA vs TAC and MMF), year of transplantation (1997 vs 1996, 1998 vs 1996, 1999 vs 1996, 2000 vs 1996), and transplant center volume (≥75 vs <75 transplants per year) were analyzed but had no statistically significant effect on allograft failure or death.…”

“…Many of these variables have been reported previously. [13][14][15][16][17] Immunosuppression at discharge (TAC and AZA vs TAC and MMF), year of transplantation (1997 vs 1996, 1998 vs 1996, 1999 vs 1996, 2000 vs 1996), and transplant center volume ( 75 vs o75 transplants per year) were analyzed but had no statistically significant effect on allograft failure or death.…”

Hemodialysis Vintage, Black Ethnicity, and Pretransplantation Antidonor Cellular Immunity in Kidney Transplant Recipients

“…Greater dialysis exposure, known to have a negative impact on patient survival after kidney transplantation (13,14), also correlates with AR and death-censored graft survival (1)(2)(3). It has been argued that dialysis may increase the risk for AR by correcting immune dysfunction related to the predialysis uremic state (2).…”

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

“…Nonetheless, there is a relative paucity of data in the literature regarding long-term outcomes of patients with LN and renal transplantation. Specifically, although in other patient cohorts undergoing renal transplantation the time spent on dialysis prior to the transplantation has been studied, showing that the longer a patient spends on dialysis, the worse the overall survival after the transplantation [11–13], this has not been specifically investigated for lupus patients. As time spent on dialysis before the transplantation can be a potentially modifiable factor, it is important to identify whether this is indeed a risk predictor in the lupus patients and whether there is a “safe maximum” time on dialysis before transplantation.…”