Mortality after Renal Allograft Failure and Return to Dialysis

Abstract

Introduction: The outcomes of patients who fail their kidney transplant and return to dialysis (RTD) has not been investigated in a nationally representative sample. We hypothesized that variations in management of transplant chronic kidney disease stage 5 leading to kidney allograft failure (KAF) and RTD, such as access, nutrition, timing of dialysis, and anemia management predict long-term survival. Methods: We used an incident cohort of patients from the United States Renal Data System who initiated hemodialysis between January 1, 2003 and December 31, 2008, after KAF. We used Cox regression analysis for statistical associations, with mortality as the primary outcome. Results: We identified 5,077 RTD patients and followed them for a mean of 30.9 ± 22.6 months. Adjusting for all possible confounders at the time of RTD, the adjusted hazards ratio (AHR) for death was increased with lack of arteriovenous fistula at initiation of dialysis (AHR 1.22, 95% CI 1.02-1.46, p = 0.03), albumin <3.5 g/dL (AHR 1.33, 95% CI 1.18-1.49, p = 0.0001), and being underweight (AHR 1.30, 95% CI 1.07-1.58, p = 0.006). Hemoglobin <10 g/dL (AHR 0.96, 95% CI 0.86-1.06, p = 0.46), type of insurance, and zip code-based median household income were not associated with higher mortality. Glomerular filtration rate <10 mL/min/1.73 m² at time of dialysis initiation (AHR 0.83, 95% CI 0.75-0.93, p = 0.001) was associated with reduction in mortality. Conclusions: Excess mortality risk observed in patients starting dialysis after KAF is multifactorial, including nutritional issues and vascular access. Adequate preparation of patients with failing kidney transplants prior to resuming dialysis may improve outcomes.

Clinical outcomes of incident peritoneal dialysis patients coming from kidney transplantation program: A case-control study

“…Some studies did not control the presence of diabetes or even the age of the patients, which are well-known risk factors for mortality [14,15]. Other factors such as pre-dialysis care, albumin, hemoglobin, residual diuresis and glomerular filtration rate have been associated with mortality in patients undergoing dialysis after graft loss [16]. In the present study, Tx patients had higher mortality mainly due to infectious diseases, which could be partially explained by the lower albumin levels and BMI observed in this group on the time of admission in the PD program.…”

Treatment options for localised renal cell carcinoma of the transplanted kidney

“…Recent data support this position and demonstrate that for T1aN0M0 RCC a 5-year survival rate of 95% can be expected[ 9 , 44 ] whereas 5-year survival rate after allograft removal and return to dialysis is only 34%[ 8 ]. Analyses of non-cancer specific mortality after KTx failure also confirm the long-term survival benefit of maintained renal function[ 45 , 46 ].…”

Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status

“…Patients with failing kidney grafts also pose further challenging problems: signs of protein wasting are frequent, in particular in patients on long-term steroids; criteria for dialysis initiation are otherwise not different before transplantation and after graft failure [ 180 , 181 , 182 ]. The question of when and how to discontinue antirejection drugs still needs to be clarified: while the trend was to rapidly discontinue antirejection drugs as soon as dialysis was started, the trend is now to keep them at low doses at least in cases in which a further graft is possible.…”