Reduced survival and quality of life following return to dialysis after transplant failure: the Dialysis Outcomes and Practice Patterns Study

Abstract

Background: Although dialysis after kidney transplant failure (TF) is common, the outcomes of these patients remain unclear. We compared outcomes of TF patients with transplant-naïve (TN) patients wait-listed for kidney transplantation.

Methods: We used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), including laboratory markers and health-related quality of life (HR-QOL). Mortality and hospitalization of participants with one prior TF versus TN patients were compared using the Cox regression analysis. HR-QOL physical and mental component summary scores (PCS and MCS) were examined using linear mixed models, and clinical practices were compared using logistic regression.

Results: Compared with TN patients (n = 2806), TF patients (n = 1856) were younger (48 versus 51 years, P = 0.003), less likely to be diabetic (18 versus 27%, P < 0.0001) and to use a permanent surgical vascular access {adjusted odds ratio (AOR): 0.85 [95% confidence interval (CI): 0.70-1.03], P = 0.10}, particularly within the first 3 months after TF [AOR 0.45 (0.32-0.62), P < 0.0001]. TF patients also had lower PCS [mean difference -2.56 (-3.36, -1.75), P < 0.0001] but not MCS [-0.42 (-1.34, 0.50), P = 0.37]. All-cause mortality [adjusted hazard ratio (AHR): 1.32 (95% CI: 1.05-1.66), P = 0.02], especially infection-related [AHR 2.45 (95% CI: 1.36-4.41), P = 0.01], was higher among TF patients.

Conclusions: TF patients have reduced QOL and higher mortality, particularly due to infections, than TN patients. Interventions to optimize care before and after starting dialysis remain to be identified and applied in clinical practice.

Fig. 1.

Assembly of the study cohort.

Fig. 2.

Percentage of patients by country with a history of transplant failure and wait-listed for kidney transplantation at DOPPS enrollment (Phases 1–3). SP, Spain; UK, United Kingdom; SW, Sweden; FR, France; ANZ, Australia–New Zealand; CA, Canada; GE, Germany; BE, Belgium; USA, United States; IT, Italy; JP, Japan.

Fig. 3.

Mortality: TF versus TN. All models stratified by country and study phase, and accounted for facility clustering. *Model adjusted for age, sex, race, BMI, time since initiation of HD or TX failure, 13 summary comorbid conditions, albumin and catheter use.

Fig. 4.

Time to first hospitalization: TF versus TN. All models stratified by country and study phase, and accounted for facility clustering. *Model adjusted for age, sex, race, BMI, time since initiation of HD or TX failure, 13 summary comorbid conditions, albumin and catheter use.

Fig. 5.

Infection-related hospitalization or death: TF versus TN. All models stratified by country and study phase, and accounted for facility clustering. *Model adjusted for age, sex, race, BMI, time since initiation of HD or TX failure, 13 summary comorbid conditions, albumin and catheter use.