The Impact of Failed Deceased Donor Kidney Graft Longevity on Mortality

Abstract

Introduction

While the benefits of deceased donor kidney transplant versus dialysis are clear, the impact of graft longevity remains unclear.

Research Questions

This study assessed survival between patients with failed grafts and patients who remained on dialysis alone.

Design

Utilizing the Organ Procurement and Transplant Network database, adults on dialysis listed for deceased donor kidney transplant between 1/2005 and 12/2017 were identified (n = 265 280; n = 129 062 [48.7%] transplant; n = 136 218 [51.3%] dialysis alone, not transplanted). A multivariable Cox proportional hazards model incorporating confounding covariates and utilizing transplant status (dialysis alone, functioning graft, failed graft) as a time-varying covariate was constructed. Representative patients were then fit to this model to assess survival probability.

Results

Patients who underwent transplant experienced a 65% reduction in mortality compared to those remaining on dialysis. However, graft failure (n = 19 389, 15.0% of transplants) was associated with a 47% increase in hazard rate compared to dialysis. When an average-risk patient was fit to this model, with transplant 4 years after dialysis initiation, a graft required longevity of 3 years to convey a survival probability benefit at 5 years postoperatively (9 years from waitlisting, 35%) over remaining on dialysis through the same time point (9 years from waitlisting, 32%).

Conclusions

These results argue for scrutiny of anticipated graft longevity and its expected impact on individual outcomes and advocate for 3-year graft survival as a critical clinical measure for transplant programs.