Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Mar 1;105(3):668-676.
doi: 10.1097/TP.0000000000003285.

Competing Risk Analysis in Renal Allograft Survival: A New Perspective to an Old Problem

Mireille El Ters  1   2 , Byron H Smith  3 , Fernando G Cosio  1   2 , Walter K Kremers  2   3
Affiliations

Competing Risk Analysis in Renal Allograft Survival: A New Perspective to an Old Problem

Mireille El Ters et al. Transplantation. .

Abstract

Background: Graft survival after kidney transplant (KTX) is often estimated by the Kaplan-Meier (KM) method censoring for competing endpoints, primarily death. This method overestimates the incidence of graft loss.

Methods: In 3157 adult KTX recipients followed for a mean of 79.2 months, we compared kidney and patient survival probabilities by KM versus competing risk analysis (CRA). These methods are extended to comparing different regression methods.

Results: Compared with CRA, the probabilities of death and graft loss (censored for the other outcome) were substantially higher by KM. These differences increased with increasing follow-up time. Importantly, differences in graft losses were magnified in subgroups with greater probabilities of death. Among recipients with diabetes, the probabilities of graft loss at 20 years were 57% by KM and 32% by CRA, while for non-diabetes mellitus corresponding values were 44% and 35%. Similar results are noted when comparing older versus younger recipients. Finally, we find that the Fine-Gray method assumptions are violated when using age and gender as covariates and that the alternative method of Aalen-Johansen may be more appropriate.

Conclusions: CRA provides more accurate estimates of long-term graft survival and death, particularly in subgroups of recipients with higher rates of the competing event. Overestimation of risk by KM leads to both quantitative and qualitative misinterpretations of long-term KTX outcomes. When using regression analyses, care should be taken to check assumptions to guide the choice of appropriate method.

PubMed Disclaimer

References

    1. Verduijn M, Grootendorst DC, Dekker FW, et al. The analysis of competing events like cause-specific mortality–beware of the Kaplan-Meier method. Nephrol Dial Transplant. 2011; 26:56–61.
    1. Noordzij M, Leffondré K, van Stralen KJ, et al. When do we need competing risks methods for survival analysis in nephrology? Nephrol Dial Transplant. 2013; 28:2670–2677.
    1. Maradit Kremers H, Kremers WK, Sierra RJ, et al. Competing risk of death when comparing tibial implant types in total knee arthroplasty. J Bone Joint Surg Am. 2016; 98:591–596.
    1. Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. JASA. 1999; 94:496–509.
    1. Aalen OO, Johansen S. An empirical transition matrix for nonhomogeneous Markov chains based on censored observations. Scand J Stat. 1978; 5:141–150.

Publication types

LinkOut - more resources