Background: In adult kidney transplantation, there is no clear consensus on the incidence of graft failure-due-to noncompliance (GFNC), with some reporting it as relatively uncommon and others as a major cause of late graft failure. We suspected that GFNC was a major cause of late graft loss at our center but did not know the extent of this problem.
Methods: In our prospectively followed cohort of 628 adult, primary kidney-alone transplant recipients with long-term follow-up, GFNC and other graft loss causes were determined from our ongoing clinical evaluations. Using competing risks methodology, we determined the overall percentage of patients developing GFNC and the significant prognostic factors for its hazard rate and cumulative incidence (via Cox regression).
Results: Cumulative incidence estimates (±standard error) of GFNC (n=29), GF-with-compliance (n=46), receiving a never-functioning graft (n=7), and death-with-a-functioning-graft (n=53) at 101 months after transplant (last-observed-graft loss) were as follows: 9.8%±2.4%, 10.9%±1.7%, 1.1%±0.4%, and 13.0%±1.9%, respectively. Only three patients experienced GFNC during the first 24 months; GFNC represented 48.1% (26/54) of death-censored GFs beyond 24 months. Two baseline variables were jointly associated with a significantly higher GFNC hazard and cumulative incidence: younger recipient age (P<0.000001 each) and non-white recipient (P=0.004 and P=0.02). Estimated percentages of ever developing GFNC were 28.4%±6.5% among 79 non-whites younger than 35 years versus 0.0% (0/144) among whites 50 years or older. Among 302 recipients younger than 50 years, 18.1%±4.1% developed GFNC, representing 67.6% (25/37) of its death-censored graft failures observed beyond 24 months after transplant.
Conclusions: GFNC is a major cause of late GF at our center, with younger and non-white recipients at a significantly greater GFNC risk. Interventional approaches to eliminate GFNC could dramatically improve long-term kidney graft survival.
1 Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL.
2 Miami Transplant Institute, Department of Medicine, University of Miami Miller School of Medicine; Miami, FL.
3 Address correspondence to: Jeffrey J. Gaynor, Ph.D., Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, PO Box 012440 (R-440), Miami, FL 33101.
The authors declare no funding or conflicts of interest.
J.J.G. designed the research/study, performed the research/study, collected data, analyzed data, and wrote the article. G.C. and G.W.B. designed the research/study, performed the research/study, and wrote the article. G.G. designed the research/study, performed the research/study, and collected data. J.S., L.C., A.M., P.R., and R.V. performed the research/study. L.H., L.T., S.F., J.A., S.J., and Z.C collected data. D.R. and W.K. designed the research/study and performed the research/study.
Received 27 June 2013. Revision requested 29 July 2013.
Accepted 22 October 2013.