Long-term outcomes of kidney transplant recipients with end-stage kidney disease attributed to presumed/advanced glomerulonephritis or unknown cause

Abstract

People with biopsy-proven glomerulonephritis (GN) as their cause of end-stage kidney disease (ESKD) who undergo kidney transplantation incur significant risk of recurrent GN-related graft failure, but the risk in recipients with ESKD where GN was suspected but not biopsy proven (presumed/advanced GN) and when the cause of ESKD is unknown remains uncertain. Using the Australia and New Zealand Dialysis and Transplant registry, we examined the associations between primary kidney transplant recipients whose ESKD was attributed to: 1) commonly-recurring GN (i.e. IgA nephropathy, membranoproliferative GN, focal segmental glomerulosclerosis and membranous GN), 2) presumed/advanced GN, and 3) cause of ESKD unknown (uESKD) and GN-related graft failure using adjusted competing risk models. Of 5258 recipients followed for a median of 8 years, 3539 (67.3%) had commonly-recurring GN, 1195 (22.7%) presumed/advanced GN, and 524 (10.0%) uESKD. Compared to recipients with commonly-recurring GN, recipients with presumed/advanced GN or uESKD experienced a low incidence of GN-related graft failure (<1%) and a lower hazard of GN-related graft failure (adjusted sub-distribution hazard ratio [HR] 0.28 [95%CI 0.15-0.54,p < 0.001] and 0.20 [95%CI 0.06-0.64,p = 0.007], respectively). People with ESKD attributed to either presumed/advanced GN or unknown cause face a very low risk of graft failure secondary to GN recurrence after transplantation.

Figure 1

Forest plots showing the adjusted hazard ratios (HR) with 95% confidence intervals (95%CI) or subdistribution HR with 95%CI of the association between categories of end-stage kidney disease, overall graft failure, death censored graft failure, glomerulonephritis (GN)-related graft failure, death with a functioning graft and overall mortality. Cox regression and competing risk models were adjusted for donor and recipient age, ethnicity, era, waiting time and HLA-mismatches.

Figure 2

Cumulative incidence function curves of glomerulonephritis (GN)-related graft failure after kidney transplantation stratified by categories of end-stage kidney disease, adjusted for the competing risk of non-glomerulonephritis-related graft failure.

Figure 3

Cumulative incidence function curves of death censored graft failure (A) and death with a functioning graft (B) stratified by categories of end-stage kidney disease, adjusted for the competing risk of death with a functioning graft and death censored graft failure, respectively.