Patient survival after renal transplantation
- John Vella, MD, FACP, FRCP, FASN
John Vella, MD, FACP, FRCP, FASN
- Associate Professor of Medicine
- Tufts University School of Medicine
Kidney transplantation is the treatment of choice for selected patients with end-stage renal disease (ESRD) . A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients when compared with maintenance dialysis [2-4]. Survival rates posttransplantation are similar for both hemodialysis and peritoneal dialysis patients .
The following discussion will review the data relating to patient survival in patients undergoing renal transplantation. The determinants of short-term and long-term graft survival are discussed separately. (See "Risk factors for graft failure in kidney transplantation".)
Graft and patient survival after kidney transplantation have improved over the past decade. Death-censored graft survival has increased steadily over the past decade in both adults and pediatric recipients . Data provided by the Scientific Registry of Transplant Recipients (SRTR) demonstrate a 10-year overall graft survival for both living and deceased donors of approximately 55 to 60 percent compared with 35 to 40 percent from a decade prior. Death-censored graft survival in particular has improved, while death with a functioning graft has increased over the decade, mitigating improvements in overall graft survival. This is likely a reflection of better immunosuppression in the former and an older patient population with greater comorbidities in the latter.
The long-term advantages of living-donor versus deceased-donor kidney transplant are best appreciated in those with long expected longevity and fewer comorbidities, such as the pediatric population.
Among adults, both early graft loss within 90 days from transplant and estimated glomerular filtration rate (GFR) at one year following transplant improved over the last decade. A retrospective study comparing transplant outcomes (from all donor types; n = 202 expanded criteria, 642 standard criteria, and 673 living-donor transplants) to outcomes of 173 patients in an intensive home hemodialysis program (16 hours per week) in Canada demonstrated the advantage of transplantation, with a reduction in risk of mortality and treatment failure (defined as either permanent switch to alternative dialysis modality or graft loss) of over 50 percent among those transplanted, despite a higher rate of hospitalizations in the transplant cohort within the first three months .
- Suthanthiran M, Strom TB. Renal transplantation. N Engl J Med 1994; 331:365.
- Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in end-stage renal failure: evidence for reduced mortality risk compared with hemodialysis during long-term follow-up. J Am Soc Nephrol 1998; 9:2135.
- Port FK, Wolfe RA, Mauger EA, et al. Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 1993; 270:1339.
- Ojo AO, Port FK, Wolfe RA, et al. Comparative mortality risks of chronic dialysis and cadaveric transplantation in black end-stage renal disease patients. Am J Kidney Dis 1994; 24:59.
- Snyder JJ, Kasiske BL, Gilbertson DT, Collins AJ. A comparison of transplant outcomes in peritoneal and hemodialysis patients. Kidney Int 2002; 62:1423.
- Matas AJ, Smith JM, Skeans MA, et al. OPTN/SRTR 2013 Annual Data Report: kidney. Am J Transplant 2015; 15 Suppl 2:1.
- Tennankore KK, Kim SJ, Baer HJ, Chan CT. Survival and hospitalization for intensive home hemodialysis compared with kidney transplantation. J Am Soc Nephrol 2014; 25:2113.
- Evans RW, Orians CE, Ascher NL. The potential supply of organ donors. An assessment of the efficacy of organ procurement efforts in the United States. JAMA 1992; 267:239.
- Wolfe R. The state of kidney transplantation in the United States. Semin Dial 2005; 18:453.
- UNOS regulations. http://optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.PDF (Accessed on November 12, 2013).
- Arend SM, Mallat MJ, Westendorp RJ, et al. Patient survival after renal transplantation; more than 25 years follow-up. Nephrol Dial Transplant 1997; 12:1672.
- Nogueira JM, Haririan A, Jacobs SC, et al. Cigarette smoking, kidney function, and mortality after live donor kidney transplant. Am J Kidney Dis 2010; 55:907.
- Port FK, Dykstra DM, Merion RM, Wolfe RA. Trends and results for organ donation and transplantation in the United States, 2004. Am J Transplant 2005; 5:843.
- McCullough KP, Keith DS, Meyer KH, et al. Kidney and pancreas transplantation in the United States, 1998-2007: access for patients with diabetes and end-stage renal disease. Am J Transplant 2009; 9:894.
- United States Renal Data System. 2003 Annual Data Report. Am J Kidney Dis 2004; 42(Suppl 5):S1.
- Becker BN, Becker YT, Pintar TJ, et al. Using renal transplantation to evaluate a simple approach for predicting the impact of end-stage renal disease therapies on patient survival: observed/expected life span. Am J Kidney Dis 2000; 35:653.
- The 2003 SRTR report on the state of transplantation. Am J Transplant 2004; 4 (Suppl 9):54.
- Fabrizii V, Winkelmayer WC, Klauser R, et al. Patient and graft survival in older kidney transplant recipients: does age matter? J Am Soc Nephrol 2004; 15:1052.
- Keith DS, Demattos A, Golconda M, et al. Effect of donor recipient age match on survival after first deceased donor renal transplantation. J Am Soc Nephrol 2004; 15:1086.
- Wu C, Evans I, Joseph R, et al. Comorbid conditions in kidney transplantation: association with graft and patient survival. J Am Soc Nephrol 2005; 16:3437.
- Abbott KC, Glanton CW, Trespalacios FC, et al. Body mass index, dialysis modality, and survival: analysis of the United States Renal Data System Dialysis Morbidity and Mortality Wave II Study. Kidney Int 2004; 65:597.
- Glanton CW, Kao TC, Cruess D, et al. Impact of renal transplantation on survival in end-stage renal disease patients with elevated body mass index. Kidney Int 2003; 63:647.
- Yeo FE, Villines TC, Bucci JR, et al. Cardiovascular risk in stage 4 and 5 nephropathy. Adv Chronic Kidney Dis 2004; 11:116.
- Ojo AO. Cardiovascular complications after renal transplantation and their prevention. Transplantation 2006; 82:603.
- US Renal Data System. USRDS 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD 2008.
- Cosio FG, Hickson LJ, Griffin MD, et al. Patient survival and cardiovascular risk after kidney transplantation: the challenge of diabetes. Am J Transplant 2008; 8:593.
- Herzog CA, Ma JZ, Collins AJ. Long-term survival of renal transplant recipients in the United States after acute myocardial infarction. Am J Kidney Dis 2000; 36:145.
- Lentine KL, Brennan DC, Schnitzler MA. Incidence and predictors of myocardial infarction after kidney transplantation. J Am Soc Nephrol 2005; 16:496.
- Herzog CA, Ma JZ, Collins AJ. Long-term outcome of renal transplant recipients in the United States after coronary revascularization procedures. Circulation 2004; 109:2866.
- Ferguson ER, Hudson SL, Diethelm AG, et al. Outcome after myocardial revascularization and renal transplantation: a 25-year single-institution experience. Ann Surg 1999; 230:232.
- Lentine KL, Schnitzler MA, Abbott KC, et al. De novo congestive heart failure after kidney transplantation: a common condition with poor prognostic implications. Am J Kidney Dis 2005; 46:720.
- Lentine KL, Schnitzler MA, Abbott KC, et al. Incidence, predictors, and associated outcomes of atrial fibrillation after kidney transplantation. Clin J Am Soc Nephrol 2006; 1:288.
- Locatelli F, Pozzoni P, Del Vecchio L. Renal replacement therapy in patients with diabetes and end-stage renal disease. J Am Soc Nephrol 2004; 15 Suppl 1:S25.
- Lufft V, Dannenberg B, Schlitt HJ, et al. Cardiovascular morbidity and mortality in patients with diabetes mellitus type I after kidney transplantation: a case-control study. Clin Nephrol 2004; 61:238.
- Rubin RH. Infectious disease complications of renal transplantation. Kidney Int 1993; 44:221.
- Meier-Kriesche HU, Arndorfer JA, Kaplan B. Association of antibody induction with short- and long-term cause-specific mortality in renal transplant recipients. J Am Soc Nephrol 2002; 13:769.
- Woo YM, Jardine AG, Clark AF, et al. Early graft function and patient survival following cadaveric renal transplantation. Kidney Int 1999; 55:692.
- Ojo AO, Hanson JA, Wolfe RA, et al. Long-term survival in renal transplant recipients with graft function. Kidney Int 2000; 57:307.
- Meier-Kriesche HU, Schold JD, Srinivas TR, Kaplan B. Lack of improvement in renal allograft survival despite a marked decrease in acute rejection rates over the most recent era. Am J Transplant 2004; 4:378.
- Howard RJ, Patton PR, Reed AI, et al. The changing causes of graft loss and death after kidney transplantation. Transplantation 2002; 73:1923.
- Briggs JD. Causes of death after renal transplantation. Nephrol Dial Transplant 2001; 16:1545.
- Grenfell A, Bewick M, Snowden S, et al. Renal replacement for diabetic patients: experience at King's College Hospital 1980-1989. Q J Med 1992; 85:861.
- Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341:1725.
- Rabbat CG, Thorpe KE, Russell JD, Churchill DN. Comparison of mortality risk for dialysis patients and cadaveric first renal transplant recipients in Ontario, Canada. J Am Soc Nephrol 2000; 11:917.
- Meier-Kriesche HU, Ojo AO, Port FK, et al. Survival improvement among patients with end-stage renal disease: trends over time for transplant recipients and wait-listed patients. J Am Soc Nephrol 2001; 12:1293.
- Oniscu GC, Brown H, Forsythe JL. Impact of cadaveric renal transplantation on survival in patients listed for transplantation. J Am Soc Nephrol 2005; 16:1859.
- Gill JS, Tonelli M, Johnson N, et al. The impact of waiting time and comorbid conditions on the survival benefit of kidney transplantation. Kidney Int 2005; 68:2345.
- Meier-Kriesche HU, Kaplan B. Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis. Transplantation 2002; 74:1377.
- Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol 2001; 12:589.
- Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 2005; 294:2726.
- Snoeijs MG, Schaubel DE, Hené R, et al. Kidneys from donors after cardiac death provide survival benefit. J Am Soc Nephrol 2010; 21:1015.
- Schold JD, Meier-Kriesche HU. Which renal transplant candidates should accept marginal kidneys in exchange for a shorter waiting time on dialysis? Clin J Am Soc Nephrol 2006; 1:532.
- Ojo A, Wolfe RA, Agodoa LY, et al. Prognosis after primary renal transplant failure and the beneficial effects of repeat transplantation: multivariate analyses from the United States Renal Data System. Transplantation 1998; 66:1651.
- Rao PS, Schaubel DE, Wei G, Fenton SS. Evaluating the survival benefit of kidney retransplantation. Transplantation 2006; 82:669.
- Meier-Kriesche HU, Schold JD, Srinivas TR, et al. Kidney transplantation halts cardiovascular disease progression in patients with end-stage renal disease. Am J Transplant 2004; 4:1662.
- Lentine KL, Rocca Rey LA, Kolli S, et al. Variations in the risk for cerebrovascular events after kidney transplant compared with experience on the waiting list and after graft failure. Clin J Am Soc Nephrol 2008; 3:1090.
- Cueto-Manzano AM, Morales-Buenrostro LE, González-Espinoza L, et al. Markers of inflammation before and after renal transplantation. Transplantation 2005; 80:47.
- Ducloux D, Kazory A, Chalopin JM. Predicting coronary heart disease in renal transplant recipients: a prospective study. Kidney Int 2004; 66:441.
- Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med 2005; 352:1685.
- Makita Z, Bucala R, Rayfield EJ, et al. Reactive glycosylation endproducts in diabetic uraemia and treatment of renal failure. Lancet 1994; 343:1519.
- Lopez-Gomez JM, Verde E, Perez-Garcia R. Blood pressure, left ventricular hypertrophy and long-term prognosis in hemodialysis patients. Kidney Int Suppl 1998; 68:S92.
- McGregor E, Jardine AG, Murray LS, et al. Pre-operative echocardiographic abnormalities and adverse outcome following renal transplantation. Nephrol Dial Transplant 1998; 13:1499.
- Simmons EM, Langone A, Sezer MT, et al. Effect of renal transplantation on biomarkers of inflammation and oxidative stress in end-stage renal disease patients. Transplantation 2005; 79:914.
- ESTIMATED POSTTRANSPLANT SURVIVAL
- FACTORS ASSOCIATED WITH PATIENT SURVIVAL
- Allograft source
- Patient and deceased-donor age
- Comorbid conditions
- - Cardiovascular disease
- - Diabetes mellitus
- Overall immunosuppression
- Allograft function
- CAUSES OF DEATH
- SURVIVAL COMPARED WITH DIALYSIS
- Reasons for improved survival
- INFORMATION FOR PATIENTS