The association of pretransplant dialysis exposure with transplant failure is dependent on the state-specific rate of dialysis mortality

Abstract

Longer pretransplant dialysis exposure is associated with a higher risk of transplant failure. Whether patients who receive dialysis in a region with a higher rate of dialysis mortality are a higher risk for transplant failure is unknown. Adjusted state‐specific hemodialysis mortality rates were determined in 3‐year intervals among prevalent dialysis patients in the United States between 1995 and 2012. The effect of state‐ and period‐specific dialysis mortality on the association of pretransplant dialysis exposure with transplant survival through December 2017 was determined using multivariable models. Dialysis mortality within states ranged from 128 deaths/1000 patient‐years to 330 deaths/1000 patient‐years. Each additional year of dialysis was associated with a 4% higher risk of transplant failure in states within the lowest quartile of dialysis mortality, compared with an 8% higher risk in states within the highest quartile of dialysis mortality. Patients who received pretransplant dialysis treatment in a state with a high rate of dialysis mortality are at a higher risk for transplant failure compared with patients with the same duration of pretransplant dialysis treatment in a state with a lower mortality rate. The findings may have implications for dialysis care in transplant candidates and the design of future outcome metrics.

Pre‐transplant maintenance dialysis duration and outcomes after kidney transplantation: A multicenter population‐based cohort study

“…Yet, as seen in our study, only about one‐quarter (28%) of patients receive a pre‐emptive transplant or have a dialysis duration less than 1.45 years. Policies to decrease these wait times are urgently needed (e.g., expanding the deceased donor organ pool); it remains to be seen if national policies aimed at increasing transplantation (i.e., Advancing American Kidney Health Executive Order in the United States) may help to reduce time on dialysis 38 Furthermore, improvements in dialysis care may also need attention 39 …”

Comparing the Net Benefits of Adult Deceased Donor Kidney Transplantation for a Patient on the Preemptive Waiting List vs a Patient Receiving Dialysis

“… 11 Mortality among patients who received a transplant after undergoing dialysis for more than 1 year is assumed be higher and increased with time spent receiving dialysis. 14 Fifth, death-censored graft loss in a recipient who has been on dialysis is assumed to be 1.25-fold higher than death-censored graft loss in a preemptive recipient. 11 Sixth, preemptive patient and graft survival is independent of eGFR at the time of transplantation.…”

“… 11 For patients transplanted after 1 to 2, 2 to 3, 3 to 4, and 4 to 5 years of dialysis, the values (for those transplanted from the dialysis waiting list) were 1.10, 1.18, 1.24, 1.35, respectively. 14 c Mortality on the dialysis WL modeled to increase with time. 16 Patients transitioning from the preemptive WL to dialysis were modeled to have a higher mortality in the first year.…”

“… 11 For patients transplanted after 1 to 2, 2 to 3, 3 to 4, and 4 to 5 years of dialysis, the values (for those transplanted from the dialysis waiting list) were 1.10, 1.18, 1.24, 1.35, respectively. 14 …”

Pretransplant dialysis exposure and outcomes after kidney transplantation – Where quantity and quality intersect?

“…In this issue of AJT , Gill et al examine the important issue of whether the association between dialysis vintage and risk of graft loss varies by state dialysis mortality rates 1 . Using data from the United States Renal Data System (USRDS), the authors found that every additional year of dialysis was associated with a 4% higher risk of graft failure in states with the lowest quartile of dialysis mortality but 8% higher risk in states with the highest quartile of dialysis mortality.…”