Long-term Mortality After Kidney Transplantation in a Nationwide Cohort of Patients With Type 1 Diabetes in Finland

Abstract

OBJECTIVETo examine time trends in mortality rates and causes of death in patients with type 1 diabetes and end-stage renal disease on dialysis and after kidney transplantation. RESEARCH DESIGN AND METHODSIn a nationwide retrospective cohort analysis, all patients with type 1 diabetes in Finland who received a kidney transplant alone were compared with patients who remained on dialysis. The main outcome was patient survival after starting dialysis. The cohort was divided into dialysis, functioning kidney transplant, and dialysis after transplant loss. Causes of death were retrieved and standardized mortality ratios calculated. RESULTSWe studied 2,383 patients. Patients survived a median of 15.9 years after a successful transplant, 11.2 years if transplant function was lost, and 2.9 years if they remained on chronic dialysis. Standardized mortality ratio decreased in all subgroups during the past four decades: from 2005 onwards, it was 3.9 in patients receiving a kidney transplant, 11.5 in patients with graft loss, and 32.5 in patients on dialysis. The most common cause of death in all patients was ischemic heart disease (45%) followed by infection (18%), which was more common in patients on dialysis. CONCLUSIONSKidney transplantation is the treatment of choice for patients with type 1 diabetes and end-stage renal disease because it substantially reduces the excess death risk when compared with dialysis. Even when kidney graft function is lost, the excess death risk is still considerably lower. Although overall mortality has decreased over the years, premature death due to ischemic heart disease remains high.Type 1 diabetes (T1D), a common disease in children and young adults, is associated with high risk of both acute and chronic complications. Diabetic nephropathy is a severe complication in patients with T1D, and in Finland, recent data show that 7.0% of the patients progress to end-stage renal disease (ESRD) after 30 years of T1D (1), whereas in the U.S., 25% have been shown to progress to ESRD after 40 years of T1D (2). Moreover, registry data show that between 4 and 17% of patients starting renal replacement treatment (RRT) have T1D (3,4). It is well known that patients with ESRD carry a manifold increased risk of premature mortality when compared with the general population, and this is particularly true for patients with T1D (5,6).

Long-term mortality among kidney transplant recipients with and without diabetes: a nationwide cohort study in the USA

“…In Finland, among 1100 kidney transplant recipients with T1D, SMRs declined 58% between 1964–1990 and 2006–2016 despite an apparent plateau in SMRs from 2000 onwards. 28 In our study, SMRs in the population with T1D declined at a relatively consistent rate (APC: −2.2, p<0.05) between 2000 and 2017. For people without diabetes, we showed a significant decline in SMR between 2000 and 2008 (APC: −5.7, p<0.05), which continued between 2008 and 2017 but at a slower rate (APC: −1.8, p<0.05).…”

Relative survival and quality of life benefits of pancreas–kidney transplantation, deceased kidney transplantation and dialysis in type 1 diabetes mellitus—a probabilistic simulation model

“…They found a considerable survival advantage for transplanted recipients (deceased or living donor kidney or SPK) compared to waitlisted patients on dialysis, with 5‐year survival 76% vs. 32%, respectively. The benefits of deceased donor kidney transplantation for long‐term survival and quality of life when compared to dialysis are well‐established [20–23]. The survival advantage associated with kidney transplantation (compared with dialysis) extends even to patients with allograft failure and return to dialysis.…”

“…Ortiz et al . [23] indicated a median survival of 15.7 years [95% CI 14.5–16.8] for patients who maintained kidney allograft function, 10.6 years [9.6, 11.7] for patients with kidney allograft failure and return to dialysis, and 2.2 years [2.0, 2.3] for those remaining on dialysis. Douzdijan et al ., Knoll et al .…”

Relationship between ABO blood groups and cardiovascular disease in type 1 diabetes according to diabetic nephropathy status

“…CVD is a major cause of premature mortality in individuals with type 1 diabetes, especially if diabetic nephropathy (DN) is present [12][13][14]. Acute diabetic complications drive the mortality rate during the first years of living with type 1 diabetes, but IHD becomes the main cause of premature mortality of those with longer duration of diabetes [15].…”