Initiation of dialysis for kidney graft failure: a retrospective single‐center cohort study

Background: The frequency and outcomes of starting maintenance dialysis in the hospital as an inpatient in kidney transplant recipients with graft failure are poorly understood. Objective: To determine the frequency of inpatient dialysis starts in patients with kidney graft failure and examine whether dialysis start status (hospital inpatient vs outpatient setting) is associated with all-cause mortality and kidney re-transplantation. Design: Population-based cohort study. Setting: We used linked administrative healthcare databases from Ontario, Canada. Patients: We included 1164 patients with kidney graft failure from 1994 to 2016. Measurements: All-cause mortality and kidney re-transplantation. Methods: The cumulative incidence function was used to calculate the cumulative incidence of all-cause mortality and kidney re-transplantation, accounting for competing risks. Subdistribution hazard ratios from the Fine and Gray model were used to examine the relationship between inpatient dialysis starts (vs outpatient dialysis start [reference]) and the dependent variables (ie, mortality or re-transplant). Results: We included 1164 patients with kidney graft failure. More than half (55.8%) of patients with kidney graft failure, initiated dialysis as an inpatient. Compared with outpatient dialysis starters, inpatient dialysis starters had a significantly higher cumulative incidence of mortality and a significantly lower incidence of kidney re-transplantation ( P < .001). The 10-year cumulative incidence of mortality was 51.9% (95% confidence interval [CI]: 47.4, 56.9%) (inpatient) and 35.3% (95% CI: 31.1, 40.1%) (outpatient). After adjusting for clinical characteristics, we found inpatient dialysis starters had a significantly increased hazard of mortality in the first year after graft failure (hazard ratio: 2.18 [95% CI: 1.43, 3.33]) but at 1+ years there was no significant difference between groups. Limitations: Possibility of residual confounding and unable to determine inpatient dialysis starts that were unavoidable. Conclusions: In this study we identified that most patients with kidney graft failure had inpatient dialysis starts, which was associated with an increased risk of mortality. Further research is needed to better understand the reasons for an inpatient dialysis start in this patient population.

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Long-term outcomes after kidney transplant failure and variables related to risk of death and probability of retransplant: Results from a single-center cohort study in Brazil

PLoS ONE ◽

10.1371/journal.pone.0245628 ◽

2021 ◽

Vol 16 (1) ◽

pp. e0245628

Author(s):

Lúcio R. Requião-Moura ◽

Cássio R. Moreira Albino ◽

Paula Rebello Bicalho ◽

Érika de Arruda Ferraz ◽

Luciana Mello de Mello Barros Pires ◽

...

Keyword(s):

Cohort Study ◽

Cox Regression ◽

Graft Loss ◽

Blood Type ◽

Kidney Graft ◽

Single Center ◽

Av Fistula ◽

Risk Of Death ◽

Transplant Patients ◽

Kaplan Meier

Background Returning to dialysis after kidney graft loss (GL) is associated with a high risk of mortality, mainly in the first 3–6 months. The follow-up of patients with GL should be extended to better understand crude patient outcomes, mainly in emerging countries, where the transplantation activity has increased. Methods This is a historical single-center cohort study conducted in an emerging country (Brazil) that included 115 transplant patients with kidney allograft failure who were followed for 44.1 (21.4; 72.6) months after GL. The outcomes were death or retransplantation after GL calculated by Kaplan-Meier and log-rank tests. Proportional hazard ratios for death and retransplantation were assessed by Cox regression. Results The 5-year probability of retransplantation was 38.7% (95% CI: 26.1%-51.2%) and that of death was 37.7% (95% CI: 24.9%-50.5%); OR = 1.03 (95% CI: 0.71–1.70) and P = 0.66. The likelihood of retransplantation was higher in patients who resumed dialysis with higher levels of hemoglobin (HR = 1.22; 95% CI = 1.04–1.43; P = 0.01) and lower in blood type O patients (HR = 0.48; 95% CI = 0.25–0.93; P = 0.03), which was associated with a lower frequency of retransplantation with a subsequent living-donor kidney. On the other hand, the risk of death was significantly associated with Charlson comorbidity index (HR for each point = 1.37; 95% CI 1.19–1.50; P<0.001), and residual eGFR at the time when patients had resumed to dialysis (HR for each mL = 1.14; 95% CI = 1.05–1.25; P = 0.002). The trend toward a lower risk of death when patients had resumed to dialysis using AV fistula access was observed (HR = 0.50; 95% CI 0.25–1.02; P = 0.06), while a higher risk seems to be associated with the number of previous engraftment (HR = 2.01; 95% CI 0.99–4.07; P = 0.05). Conclusions The 5-year probability of retransplantation was not less than that of death. Variables related to the probability of retransplantation were hemoglobin level before resuming dialysis and ABO blood type, while the risk of death was associated with comorbidities and residual eGFR.

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Kidney graft outcomes in living-related transplantation have improved with substitution of basiliximab and mycophenolate mofetil for antithymocyte globulin and azathioprine: A single center retrospective cohort study

European Journal of Internal Medicine ◽

10.1016/j.ejim.2010.09.012 ◽

2010 ◽

Vol 21 (6) ◽

pp. 524-529

Author(s):

Goran Imamović ◽

Enver Zerem ◽

Enes Osmanović

Keyword(s):

Cohort Study ◽

Mycophenolate Mofetil ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Antithymocyte Globulin ◽

Kidney Graft ◽

Single Center ◽

Living Related

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Association of Circulating Trimethylamine N-Oxide and Its Dietary Determinants with the Risk of Kidney Graft Failure: Results of the TransplantLines Cohort Study

Nutrients ◽

10.3390/nu13010262 ◽

2021 ◽

Vol 13 (1) ◽

pp. 262

Author(s):

Jose L. Flores-Guerrero ◽

Maryse C. J. Osté ◽

Paula B. Baraldi ◽

Margery A. Connelly ◽

Erwin Garcia ◽

...

Keyword(s):

Cohort Study ◽

Prediction Model ◽

Graft Failure ◽

Clinical Utility ◽

The Body ◽

Renal Transplant Recipients ◽

Kidney Graft ◽

Net Benefit ◽

Increased Risk ◽

Modifiable Factors

Background. Due to the critical shortage of kidneys for transplantation, the identification of modifiable factors related to graft failure is highly desirable. The role of trimethylamine-N-oxide (TMAO) in graft failure remains undetermined. Here, we investigated the clinical utility of TMAO and its dietary determinants for graft failure prediction in renal transplant recipients (RTRs). Methods. We included 448 RTRs who participated in the TransplantLines Cohort Study. Cox proportional-hazards regression analyses were performed to study the association of plasma TMAO with graft failure. Net Benefit, which is a decision analysis method, was performed to evaluate the clinical utility of TMAO and dietary information in the prediction of graft failure. Results. Among RTRs (age 52.7 ± 13.1 years; 53% males), the baseline median TMAO was 5.6 (3.0–10.2) µmol/L. In multivariable regression analysis, the most important dietary determinants of TMAO were egg intake (Std. β = 0.09 [95%CI, 0.01; 0.18]; p = 0.03), fiber intake (Std. β = −0.14 [95%CI, −0.22, −0.05]; p = 0.002), and fish and seafood intake (Std. β = 0.12 [95%CI, 0.03,0.21]; p = 0.01). After a median follow-up of 5.3 (4.5–6.0) years, graft failure was observed in 58 subjects. TMAO was associated with an increased risk of graft failure, independent of age, sex, the body mass index (BMI), blood pressure, lipids, albuminuria, and the Estimated Glomerular Filtration Rate (eGFR) (Hazard Ratio per 1-SD increase of TMAO, 1.62 (95% confidence interval (CI): 1.22; 2.14, p < 0.001)). A TMAO and dietary enhanced prediction model offered approximately double the Net Benefit compared to a previously reported, validated prediction model for future graft failure, allowing the detection of 21 RTRs per 100 RTRs tested, with no false positives versus 10 RTRs, respectively. Conclusions. A predictive model for graft failure, enriched with TMAO and its dietary determinants, yielded a higher Net Benefit compared with an already validated model. This study suggests that TMAO and its dietary determinants are associated with an increased risk of graft failure and that it is clinically meaningful.

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Plasma Vitamin C and Risk of Late Graft Failure in Kidney Transplant Recipients: Results of the TransplantLines Biobank and Cohort Study

Antioxidants ◽

10.3390/antiox10050631 ◽

2021 ◽

Vol 10 (5) ◽

pp. 631

Author(s):

Camilo G. Sotomayor ◽

Nicolas I. Bustos ◽

Manuela Yepes-Calderon ◽

Diego Arauna ◽

Martin H. de Borst ◽

...

Keyword(s):

Cohort Study ◽

Vitamin C ◽

Kidney Transplant ◽

Graft Failure ◽

Cox Regression ◽

Plasma Vitamin ◽

Kidney Graft ◽

Transplant Recipients ◽

Kidney Transplant Recipients ◽

Risk Of Death

Recent studies have shown that depletion of vitamin C is frequent in outpatient kidney transplant recipients (KTR) and that vitamin C is inversely associated with risk of death. Whether plasma vitamin C is associated with death-censored kidney graft failure remains unknown. We investigated KTR who participated in the TransplantLines Insulin Resistance and Inflammation Biobank and Cohort Study. The primary outcome was graft failure (restart of dialysis or re-transplantation). Overall and stratified (pinteraction < 0.1) multivariable-adjusted Cox regression analyses are presented here. Among 598 KTR (age 51 ± 12 years-old; 55% males), baseline median (IQR) plasma vitamin C was 44.0 (31.0–55.3) µmol/L. Through a median follow-up of 9.5 (IQR, 6.3‒10.2) years, 75 KTR developed graft failure (34, 26, and 15 events over increasing tertiles of vitamin C, log-rank p < 0.001). Plasma vitamin C was inversely associated with risk of graft failure (HR per 1–SD increment, 0.69; 95% CI 0.54–0.89; p = 0.004), particularly among KTR with triglycerides ≥1.9 mmol/L (HR 0.46; 95% CI 0.30–0.70; p < 0.001; pinteraction = 0.01) and among KTR with HDL cholesterol ≥0.91 mmol/L (HR 0.56; 95% CI 0.38–0.84; p = 0.01; pinteraction = 0.04). These findings remained materially unchanged in multivariable-adjusted analyses (donor, recipient, and transplant characteristics, including estimated glomerular filtration rate and proteinuria), were consistent in categorical analyses according to tertiles of plasma vitamin C, and robust after exclusion of outliers. Plasma vitamin C in outpatient KTR is inversely associated with risk of late graft failure. Whether plasma vitamin C‒targeted therapeutic strategies represent novel opportunities to ease important burden of graft failure necessitates further studies.

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