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Outcomes in Older Kidney Transplant Recipients After Prior Nonkidney Transplants

Haugen, Christine E. MD1; Luo, Xun MD, MPH1; Holscher, Courtenay M. MD1; Bowring, Mary G. MPH1; DiBrito, Sandra R. MD1; Garonzik-Wang, Jacqueline MD, PhD1; McAdams-DeMarco, Mara PhD1,2; Segev, Dorry L. MD, PhD1,2,3

doi: 10.1097/TP.0000000000002596
Original Clinical Science–General
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Background. Recipients of nonkidney solid organ transplants (nkSOT) are living longer, and 11%–18% will develop end stage renal disease (ESRD). While our general inclination is to treat nkSOT recipients who develop ESRD with a kidney transplant (KT), an increasing number are developing ESRD at an older age where KT may not be the most appropriate treatment. It is possible that the risk of older age and prior nkSOT might synergize to make KT too risky, but this has never been explored.

Methods. To examine death-censored graft loss and mortality for KT recipients with and without prior nkSOT, we used Scientific Registry of Transplant Recipients data to identify 42 089 older (age ≥65) KT recipients between 1995 and 2016. Additionally, to better understand treatment options for these patients and survival benefit of KT, we identified 5023 older (age ≥65) with prior nkSOT recipients listed for subsequent KT, of whom 863 received transplants.

Results. Compared with 41 159 older KT recipients without prior nkSOT, death-censored graft loss was similar (adjusted hazard ratio [aHR]: 1.13, 95% CI: 0.93-1.37, P = 0.2), but mortality (aHR: 1.40, 95% CI: 1.28-1.54, P < 0.001) was greater for older KT recipients with prior nkSOT. Nonetheless, in a survival benefit model (survival with versus without the transplant), among older prior nkSOT recipients, KT decreased the risk of mortality by more than half (aHR: 0.47, 95% CI: 0.42-0.54, P < 0.001).

Conclusions. Older prior nkSOT recipients who subsequently develop ESRD derive survival benefit from KT, but graft longevity is limited by overall survival in this population. These findings can help guide patient counseling for this challenging population.

1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

2 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.

3 Scientific Registry of Transplant Recipients, Minneapolis, MN.

Received 12 September 2018. Revision received 15 November 2018.

Accepted 2 December 2018.

The authors declare no conflicts of interest.

This study was supported by the National Institute of Diabetes and Digestive and Kidney Disease and the National Institute of Aging: grant numbers F32AG053025 (PI: Haugen), F32DK109662 (PI: Holscher), F32DK105600 (PI: DiBrito), R01AG055781 (PI: McAdams-DeMarco), K01AG043501 (PI: McAdams-DeMarco), and K24DK101828 (PI: Segev).

C.E.H. participated in research design, writing of the paper, performance of the research, data analysis, funding, and final approval of version to be published. X.L. participated in research design, data management, performance of the research, data analysis, and final approval of version to be published. C.M.H. participated in writing of the paper, critical revisions of the manuscript, performance of the research, funding, and final approval of version to be published. M.G.B. participated in research design, data management, performance of the research, data analysis, and final approval of version to be published. S.R.D. participated in writing of the paper, critical revisions of the manuscript, performance of the research, funding, and final approval of version to be published. J.G.W. participated in research design, writing of the paper, critical revisions of the manuscript, performance of the research, and final approval of version to be published. M.M.D. participated in research design, writing of the paper, critical revisions of the manuscript, funding, and final approval of version to be published. D.L.S. participated in research design, writing of the paper, critical revisions of the manuscript, performance of the research, funding, and final approval of version to be published.

Correspondence: Dorry Segev, MD, PhD, Department of Surgery, Johns Hopkins Medical Institutions, 2000 E. Monument St, Baltimore, MD 21205. (dorry@jhmi.edu; chaugen2@jhmi.edu).

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