Waiting Time for Second Kidney Transplantation and Mortality

Abstract

Background and objectivesThe median kidney transplant half-life is 10–15 years. Because of the scarcity of donor organs and immunologic sensitization of candidates for retransplantation, there is a need for quantitative information on if and when a second transplantation is no longer associated with a lower risk of mortality compared with waitlisted patients treated by dialysis. Therefore, we investigated the association of time on waiting list with patient survival in patients who received a second transplantation versus remaining on the waiting list.Design, setting, participants, & measurementsIn this retrospective study using target trial emulation, we analyzed data of 2346 patients from the Austrian Dialysis and Transplant Registry and Eurotransplant with a failed first graft, aged over 18 years, and waitlisted for a second kidney transplantation in Austria during the years 1980–2019. The differences in restricted mean survival time and hazard ratios for all-cause mortality comparing the treatment strategies “retransplant” versus “remain waitlisted with maintenance dialysis” are reported for different waiting times after first graft loss.ResultsSecond kidney transplantation showed a longer restricted mean survival time at 10 years of follow-up compared with remaining on the waiting list (5.8 life months gained; 95% confidence interval, 0.9 to 11.1). This survival difference was diminished in patients with longer waiting time after loss of the first allograft; restricted mean survival time differences at 10 years were 8.0 (95% confidence interval, 1.9 to 14.0) and 0.1 life months gained (95% confidence interval, −14.3 to 15.2) for patients with waiting time for retransplantation of <1 and 8 years, respectively.ConclusionsSecond kidney transplant is associated with patient survival compared with remaining waitlisted and treatment by dialysis, but the survival difference diminishes with longer waiting time.

Effect of kidney replacement therapy modality after first kidney graft failure on second kidney transplantation outcomes

“…Despite this fact, after the first kidney graft failure, we observed that the probability to receive a second KT is similar to dying. Patients from our cohort were quite older (∼10 years) compared with other studies [ 7 , 15 ]. It is well-known that mortality in patients requiring dialysis after kidney graft loss is higher than in transplant-naïve peers [ 16 , 17 ].…”

“…When living donor KT is not feasible, preemptive deceased-donor kidney retransplantation represents the optimal therapy for patients who lose kidney allograft, exhibiting greater patient and graft survival, thanks to avoiding the morbidity and mortality associated with dialysis reinitiation [ 3 , 15 , 20 ]. However, this option is not always possible due to patient comorbidities or limited because of HLA sensitization, or by the fact that time on dialysis is a relevant criterion in our allocation score.…”

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

“…It is demonstrated that KT provides superior life expectancy [61][62][63] and QoL [64][65][66] than dialysis. Nonetheless, returning to dialysis after a failed transplant entails a greater risk of death than starting RRT for the first time [11,40,43,67,68]. Therefore, preserving graft function as much as possible is vital for long-term patient survival.…”

“…Ideally, a pre-emptive strategy should be adopted to ensure the best results [6][7][8][9]. However, due to the scarcity of donors, the vast majority of transplant candidates require prolonged periods of renal replacement therapy (RRT) before receiving a suitable organ [10,11].…”

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss

“…Considering the benefits of retransplantation, the 2014 British Transplant Society Guidelines for the Management of the Failing Kidney Transplant, recommend that patients suitable for retransplant should be evaluated when graft failure is anticipated within one year, and ideally provide preemptive retransplantation [ 31 ]. Timely relisting is particularly important since recently published data showed that the survival benefit of retransplantation diminishes with longer waitlist times [ 32 , 33 ].…”