Outcomes in kidney transplant recipients with allograft failure who return to dialysis
Lauren Arena1, Ahsan Alam2,3, Gong Jessica4, Andrey Cybulsky2, Alex Tom3, Laura Horowitz2, Nasim Saberi3, Rita Suri2,3.
1Internal medicine, McGill Univeristy Health Care Center, Montreal, QC, Canada; 2Nephrology , McGill Univeristy Health Care Center, Montreal, QC, Canada; 3Research Institute of the McGill University Health Center, Montreal, QC, Canada; 4Department of Medicine, McGill University, Montreal, QC, Canada
Background: Kidney transplant recipients (KTR) who return to dialysis (RTD) have high morbidity. Whether to continue immunosuppression (IS) after RTD remains uncertain and involves balancing IS-related risks with preventing terminal rejection and allo-sensitization that may preclude re-transplantation.
Objectives: We conducted a quality improvement study to characterize IS practices following RTD, and determine incidence of potential IS-related complications, catastrophic IS-related events, and re-transplantation for patients in whom IS was weaned early vs. late.
Methods: We identified all adult KTR who RTD and survived >6 months between January 2015-June 2020 at a large Canadian transplant center using this center’s transplant and dialysis databases. Comorbidities, medications, and outcomes were captured from electronic charts on pre-specified forms from RTD until death, re-transplantation, or Aug 2021. Early IS weaning was defined as discontinuing at least one agent excluding prednisone within 6 months of RTD.
Results: Of 49 included patients, 27(55%) discontinued one IS agent by 6 months, while 22(45%) were maintained on two for a median of 34 months (range 7-78 months). During median follow-up of 29 months (range 3-78), there were no between-group differences in the proportion of patients who experienced all-cause (16/27 vs. 12/22) or infection-related (8/27 vs. 7/22) hospitalisations, ICU admission (5/27 vs. 5/22), malignancy (3/27 vs. 2/22), death (6/27 vs.4/22), terminal rejection (3/27 vs. 2/22), or re-transplantation (7/27 vs. 5/22). Median baseline PRA was significantly higher in early vs. late groups, suggesting confounding by indication. Two catastrophic IS events (disseminated tuberculosis, PTLD) occurred in late weaners.
Conclusion: Almost half of KTR continued long-term double IS after RTD, and retransplantation rates were low. Cancer and death were not increased in late vs. early IS weaners, but catastrophic infection and PTLD occurred only in late weaners. Early discontinuation of one IS agent did not result in lower probability of re-transplantation and should be considered to reduce infectious complications.
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