The influence of induction therapy for kidney transplantation after a non-renal transplant

Abstract

Background and objectives: Non-renal transplant recipients who subsequently develop ESRD and undergo kidney transplantation are medically and immunologically complex due to comorbidities, high cumulative exposure to immunosuppressants, and sensitization to alloantigen from the prior transplant. Although prior non-renal transplant recipients are one of the fastest growing segments of the kidney wait list, minimal data exist to guide the use of antibody induction therapy (IT+) at the time of kidney after lung (KALu), heart (KAH), and liver (KALi) transplant.

Design, setting, participants, & measurements: This retrospective cohort study used national registry data to examine IT use and survival after kidney transplantation. Separate multivariate Cox regression models were constructed to assess patient survival for IT+ and IT- KALu (n=232), KAH (n=588), and KALi (n=736) recipients.

Results: Use of IT increased during the study period. The percentage of patients considered highly sensitized (panel reactive antibody ≥20%) was not statistically significant between IT+ and IT- groups. IT+ was not associated with improvement in 1- and 10-year patient survival for KALu (P=0.20 and P=0.22, respectively) or for KAH (P=0.90 and P=0.14, respectively). However, IT+ among KALi was associated with inferior patient survival at 1 and 10 years (P=0.04 and P=0.02, respectively).

Conclusions: Use of IT for kidney transplantation among prior non-renal transplant recipients may not offer a survival advantage in KALu or KAH. However, due to limited power, these findings should be interpreted cautiously. IT+ was associated with inferior outcomes for KALi. Use of IT should be judicially reconsidered in this complex group of recipients.

Figure 1.

Annual number of kidney transplants following previous lung, heart, and liver transplants from 1995 to 2008. IT+, received induction therapy; IT−, did not receive induction therapy.

Figure 2.

Adjusted hazard model comparing patient survival between induction therapy and non-induction (reference) therapy populations within the setting of kidney after lung, heart, or liver transplantation. Graphs represent adjusted patient survival with the number of remaining patients displayed below. The 10-year model is presented as a footnote.

Figure 3.

Adjusted patient survival of kidney after liver transplantation stratified by hepatitis C status and induction therapy. Graph represents adjusted patient survival with the number of remaining patients displayed below. The model is presented as a footnote.