Comparison of Mortality Risk for Dialysis Patients and Cadaveric First Renal Transplant Recipients in Ontario, Canada

Abstract

Abstract. In population-based studies, renal transplantation has been shown to improve survival compared to dialysis patients awaiting transplantation in the United States. However, dialysis mortality in the United States is higher than in Canada. Whether transplantation offers a survival advantage in regions where dialysis survival is superior to that in the United States is uncertain. This study examines a cohort of 1156 patients who started end-stage renal disease (ESRD) therapy and were wait-listed for cadaveric renal transplantation in the province of Ontario, Canada between January 1, 1990 and December 31, 1994. Patients were followed from wait-listing for renal transplant (n = 1156), to cadaveric first renal transplant (n = 722), to death, or to study end (December 31, 1995). The annual crude mortality rates for wait-listed dialysis patients and transplanted patients were 5.0 and 3.4%, respectively. In Cox proportional hazards models, mortality in wait-listed patients was associated with increased age and diabetes, but not time from onset of ESRD to wait-listing. Factors associated with death following transplantation include older age, diabetes, and longer time spent on the waiting list before transplantation. In a time-dependent Cox regression model, the relative risk of death after transplantation compared to dialysis varied in a time-dependent manner. Covariates associated with increased risk included older age, diabetes, and time from onset of ESRD to wait-listing. The average relative risk (RR) of dying was 2.91 (95% confidence interval [CI], 1.34 to 6.32) in the first 30 d after transplantation, but was significantly lower 1 yr after transplantation (RR 0.25; 95% CI, 0.14 to 0.42), indicating a beneficial long-term effect when compared to wait-listed dialysis patients. This long-term benefit was most evident in subgroups of patients with diabetes (RR 0.38; 95% CI, 0.17 to 0.87) and glomerulonephritis (RR 0.13; 95% CI, 0.04 to 0.39) as the cause of ESRD. The survival advantage associated with renal transplantation is evident in this cohort of patients with a lower wait-listed dialysis mortality than that reported previously in the United States. The magnitude of the treatment effect is consistent across studies.

Impact of diabetes mellitus developing after kidney transplantation on patient mortality and graft survival: a meta-analysis of adjusted data

“…Over the last few decades, the role of kidney transplantation for managing ESRD has increased significantly and it can be attributed to the cost-effective nature of the treatment with lowered impact on patients’ quality of life as compared to dialysis [ 33 ]. While mortality rates of transplant patients are lower than those on maintenance dialysis, overall patient survival is still worse as compared to the general population [ 34 ]. In this context, efforts have been directed to improve patients’ survival as well as graft survival in kidney transplantation patients.…”

Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis

“…65 Although 44 studies showed an overall benefit favouring transplantation, 11 of those studies identified stratums in which transplantation offered no statistically significant benefit over remaining on dialysis. No difference was reported in patients with kidney failure caused by glomerulonephritis 25 ; patients aged 65-70 years 28 ; patients with kidney failure caused by hypertension or a hereditary cause 30 ; patients with body mass index ≥41 35 ; patients aged ≥70 years with kidney failure caused by glomerulonephritis 45 ; patients receiving standard criteria donor transplantation compared with those on nocturnal haemodialysis 49 ; patients aged ≥70 years on dialysis between 1990 and 1999 50 ; patients classified as being at low risk by the American Society of Transplantation 52 ; patients with peripheral arterial disease receiving deceased donor allografts 59 ; patients aged ≥70 years 67 ; and patients with chronic obstructive pulmonary disease, aged ≥70 years, or with kidney failure caused by diabetes. 58 No study described an overall lower mortality risk associated with dialysis, with 8% (n=4/48) of studies showing no difference in long term survival between treatment modalities.…”

Equity or Equality? Which Approach Brings More Satisfaction in a Kidney-Exchange Chain?

“…Therefore, many researchers have worked on prediction models for kidney-graft survival, classified into three categories: simulation and operation research, conventional statistics, and data analytic approaches [33]. A known subcategory of conventional statistical studies is the Cox proportional hazards model, a widely used multivariate approach in medical literature to assess survival time, which can be utilized for categorical and numerical types of predictors [34][35][36][37][38]. This model aims to evaluate the effects of several variables/covariates on the rate of a specific event (e.g., graft failure) at a particular point in time.…”