Detrimental consequences of early graft loss after kidney transplantation: conclusions from a nationwide evaluation

M.J. de Kok, A.F. Schaapherder, J.W. Mensink, A.P.J. de Vries, M.E.J. Reinders, C. Konijn, F.J. Bemelman, J. van de Wetering, A.D. van Zuilen, M.H.L. Christiaans, M.C. Baas, S.A. Nurmohamed, S. P. Berger, R.J. Ploeg, I.P.J. Alwayn, J.H. Lindeman

Wednesday 4 march 2020

14:20 - 14:30h at Theaterzaal

Parallel session: Parallel sessie III – Klinische abstracts

Background: Early graft loss (EGL) is a feared outcome of kidney transplantation. Consequently, kidneys with an anticipated risk of EGL are declined for transplantation. While a permissive policy towards anticipated high-risk organs will result in unacceptable high incidences of EGL, a more reticent attitude will compromise the donor usage, and as such contribute to increasing organ shortages and longer waiting list times. In the most favorable scenario, with optimal use of available donor kidneys, the donor pool size is balanced by the risk of EGL, with a tradeoff dictated by the consequences of EGL. Therefore, we considered a systematic evaluation of the impact of EGL relevant.

Methods: This observational study included all deceased-donor kidney transplantations performed in The Netherlands between 1990 and 2018 (n=11,415). Combined organ procedures, procedures with grafts donated after uncontrolled circulatory death, and procedures in recipients younger than 12 years were excluded. The remaining 10,307 procedures were used for analysis. Multivariate regression analysis was used to identify factors associated with EGL. Cox proportional hazards analyses were performed to evaluate differences in patient and death censored graft survival. EGL is defined as graft loss within 90 days after transplantation.

Results: The incidence of EGL in primary transplantation was 8.2% (699/8,511). The main causes were graft rejection (30%), primary non-function (25%), and thrombosis/infarction (20%). EGL profoundly impacted short- and long-term patient survival (adjusted HR; 95% CI: 8.2; 5.1-13.2, resp. 1.7; 1.3-2.1). Of the EGL recipients who survived 90 days after transplantation (617/699) 71% (440/617) was relisted for re-transplantation, leading to an actual re-transplantation rate of 43%. Noticeably, re-transplantation was associated with a doubled incidence of EGL, but long-term graft survival was equal to the reference group (adjusted HR 1.1; 0.6-1.8).

Conclusions: In conclusion, this nationwide study shows that EGL is associated with significant detrimental consequences that include profound short-term and long-term mortality rates, a reduced chance of relisting and re-transplantation, and for those re-transplanted an increased risk of recurrent EGL. While the development of EGL, and the associated poor outcomes are generally attributed to the use of suboptimal kidney grafts and procedural aspects, the data in this study imply convergence of recipient-associated risk factors as an eliciting factor for EGL.