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Kidney transplantation in adults: Patient survival after kidney transplantation

Kidney transplantation in adults: Patient survival after kidney transplantation
Literature review current through: Jan 2024.
This topic last updated: Sep 12, 2023.

INTRODUCTION — Kidney transplantation is the treatment of choice for selected patients with end-stage kidney disease (ESKD) [1]. A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients when compared with maintenance dialysis [2-4]. Survival rates posttransplantation are similar for both patients on hemodialysis and those on peritoneal dialysis [5].

The following discussion will review the data relating to patient survival in adult patients undergoing kidney transplantation. Patient survival in children undergoing kidney transplantation and the determinants of short-term and long-term graft survival are discussed separately:

(See "Kidney transplantation in children: Outcomes", section on 'Patient survival'.)

(See "Kidney transplantation in adults: Risk factors for graft failure".)

PATIENT SURVIVAL IN ADULT KIDNEY TRANSPLANT RECIPIENTS

Short- and long-term survival rates — Both short- and long-term patient and graft survival rates among adult kidney transplant recipients have improved over time (figure 1 and figure 2) [6,7]:

An analysis of data from the Scientific Registry of Transplant Recipients (SRTR) from 1996 to 2019 reported the following findings:

For deceased-donor kidney transplants, 10-year patient survival increased from 60.5 percent between 1996 and 1999 to 66.9 percent between 2008 and 2011. Similarly, 10-year overall graft survival increased from 42.3 percent between 1996 and 1999 to 53.6 percent between 2008 and 2011.

For living-donor kidney transplants, 10-year patient survival increased from 75.3 percent between 1996 and 1999 to 81.3 percent between 2008 and 2011. Similarly, 10-year overall graft survival increased from 53.6 percent between 1996 and 1999 to 69.6 percent between 2008 and 2011.

These improvements have occurred despite unfavorable changes in donor and recipient characteristics, such as increases in recipient and donor age, body mass index, prevalence of diabetes mellitus in both recipient and donors, duration of time on dialysis, and degree of HLA presensitization.

In a separate, large SRTR analysis of 331,216 adult solitary kidney transplants from 1995 to 2017, median survival of deceased-donor kidney transplant recipients increased from 8.2 years between 1995 and 1999 to an estimated 11.7 years between 2014 and 2017 [6]. Similarly, median survival for living-donor kidney transplant recipients increased from 12.1 years between 1995 and 1999 to an estimated 19.2 years between 2014 and 2017. The overall (deceased and living donor) adjusted hazard ratio of graft failure decreased from 0.89 (95% CI 0.88-0.91) between 2000 and 2004 to 0.46 (95% CI 0.45-0.47) between 2014 and 2017, with 1995 to 1999 as the reference.

These improvements in long-term outcomes have been attributed to multiple factors, including lower rates of acute rejection, better pretransplant crossmatch techniques, judicious use of kidney paired donation (KPD) transplants for patients with incompatible living donors, surveillance for viral infections, and effective antiviral prophylaxis [7].

Survival compared with dialysis — Given that many patients on dialysis are inappropriate candidates for kidney transplantation because of severe multiorgan disease and/or multimorbidity associated with age, the assessment of relative mortality is best performed by comparing the survival rates between patients accepted for kidney transplantation who have undergone transplant surgery with those accepted for transplantation but who have not yet received a kidney allograft (ie, patients on dialysis who are on the transplant waiting list).

Several studies using these two comparative groups have found that patient survival is overall better with kidney transplantation than with dialysis [8-10]. A 2022 systematic review of 48 observational studies (1,245,850 patients) comparing all-cause mortality between kidney transplantation and dialysis in waitlisted patients reported the following findings [9]:

The mortality risk in transplant recipients was higher than in waitlisted patients on dialysis immediately after transplantation (hazard ratio [HR] range 1.3 to 17.7 at 0 to 30 days; 1.5 to 4.8 at 0 to 3 months), which was attributable to perioperative and postoperative risk factors. However, this increased risk was eventually offset, and by one year, the mortality risk was lower in transplant recipients (HR range 0.19 to 0.49).

Improved survival with transplantation was observed among all adults ≥18 years old, older adults (variably defined as ≥60, ≥65, or ≥70 years old), and patients with obesity, diabetes, systemic sclerosis, peripheral artery disease, or hepatitis C virus as comorbidities. A greater survival benefit was observed with living-donor versus deceased-donor transplantation, standard criteria donors versus expanded criteria donors, and hepatitic C virus seronegative versus seropositive donor transplantation.

In a meta-analysis of 18 of the studies, kidney transplantation was associated with a 55 percent lower risk of long-term mortality (HR 0.45, 95% CI 0.39-0.54). However, the study authors found significant heterogeneity between studies that may limit external validity of this finding for certain patient cohorts such as older transplant candidates.

Repeat kidney transplantation after a failed primary transplant also may confer a survival benefit [11,12]. In a large series of over 19,000 kidney transplant recipients with primary allograft failure, repeat kidney transplantation was associated with a 45 and 23 percent reduction in mortality at five years for patients with type 1 diabetes mellitus and those without diabetes, respectively, compared with those remaining on the waiting list [11]. Since patients with a failed primary transplant may comprise nearly 30 percent of current waiting lists, these added survival benefits with repeat transplantation have a significant impact upon overall mortality from ESKD.

However, these data need to be interpreted with caution. Although the authors of the last study attempted to utilize a "control" group (ie, those listed for transplantation who did not actually receive a transplant), selection bias almost certainly played some role in these results. Patients listed for transplantation may not have been transplanted, due to the development of intercurrent disease that led to death. This is a limitation common to all studies that rely upon the review of registry data.

The reduction in mortality among transplant recipients, compared with patients on dialysis, is due in part to a decrease in cardiovascular events, especially among patients with diabetes. Transplantation reduces the risk of fatal and nonfatal cardiovascular complications, compared with long-term dialysis, among patients selected to be suitable transplant candidates [13-17].

Survival compared with general population — Although transplantation confers the highest survival benefit among all of the different kidney replacement therapies, kidney allograft recipients still have a high mortality rate compared with population controls. In one study, for example, the mortality of recipients of first kidney transplants was 14 times higher than the age-matched population without kidney failure during the first year after transplantation and was four times higher after this period [18].

FACTORS THAT AFFECT PATIENT SURVIVAL — Patient survival after kidney transplantation varies based upon the source of the allograft, patient age, and the presence and degree of severity of comorbid conditions. Other possible contributing factors include sex, race, and level of cumulative immunosuppression.

Allograft source — The survival of patients receiving an allograft from a living donor is superior to those who receive a kidney from a deceased donor, including both nonexpanded-criteria and expanded-criteria donors [19,20]:

For recipients of living-donor kidney transplants, patient survival rate at five years posttransplantation is 91 percent.

For recipients of deceased, standard criteria donor transplants, the survival rate is 84 percent.

For recipients of deceased, kidney donor profile index (KDPI) >85 donor transplants, the survival rate is 70 percent.

The KDPI >85 percent has replaced the expanded-donor-criteria terminology based on the observation that many factors impact organ quality and outcomes (see "Kidney transplantation in adults: Organ sharing"). The outcomes of recipients who receive such kidneys with higher KDPIs decline slowly until KDPI exceeds 85 percent. Kidneys with a KDPI >85 percent approximate the prior expanded-donor-criteria definitions, if imperfectly. The outcomes of such transplants were evaluated in a study that compared the survival of candidates older than 60 years who either received a KDPI >85 percent allograft or remained on dialysis [21]. Mortality after the first posttransplant year was markedly reduced in those who received such higher-risk kidneys (either preemptively before the need for dialysis or nonpreemptively after dialysis initiation) compared with those who were listed but never transplanted.

Recipient and deceased-donor age — Patients of increasing age who undergo kidney transplantation have a higher mortality rate than younger recipients (figure 3) [22]. In the 2021 Scientific Registry of Transplant Recipients (SRTR) report on the state of transplantation, for example, the one- and five-year survival rates for children age 6 to 11 years who received a deceased-donor kidney were 99 and 97 percent, respectively [23].

Although lower than in children, survival of the older transplant recipient is currently excellent. With present therapy, the survival at one and five years of patients >65 years of age is approximately 93 and 73 percent, respectively, for deceased-donor transplants and 98 and 84 percent, respectively, for living-donor transplants [23]. As a result, the older patient on dialysis should not be excluded as a possible transplant recipient based upon age alone. (See "Kidney transplantation and the older adult patient".)

Comorbid conditions — The presence of systemic disorders, particularly vascular disease, is associated with poorer long-term patient survival after kidney transplantation. In a single-center study, high comorbidity (as assessed by the Charlson comorbidity index) correlated with an increased risk of death in both the perioperative period (hazard ratio [HR] 3.20) and more than three months after transplantation [24].

Patients with disease primarily affecting the kidney, such as autosomal dominant polycystic kidney disease and glomerulonephritis, have better long-term survival than those with systemic disorders, such as hypertension and diabetes. Obesity is also associated with an increased risk of death [25,26].

Cardiovascular disease — Fifty to 60 percent of deaths among kidney transplant recipients are directly attributable to cardiovascular disease, which has a reported incidence of approximately 1 per 100 person-years at risk [27,28]. Death from cardiovascular disease is also the most common cause of graft loss, accounting for 30 percent of graft loss from death overall, with the greatest rates early after transplant [29]. However, one must keep in mind that most of the deaths attributable to cardiovascular disease are among those with diabetes, whereas infection, malignancy, and others are more commonly the cause of death among those without diabetes [17].

Since cardiovascular disease is the leading cause of death for adult kidney allograft recipients, it is important to evaluate the extent and severity of coronary disease prior to transplantation (see "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient"). Nearly one-third of all such deaths are due to acute myocardial infarction (MI), with patients with diabetes having the worst survival post-MI [13,30].

Among those who require intervention for coronary artery disease after transplantation, myocardial revascularization is associated with acceptable immediate and long-term survival and similar outcomes with percutaneous and surgical techniques:

In a retrospective study of kidney transplant recipients who underwent a first coronary revascularization procedure from 1995 to 1999, in-hospital mortality was 2.3, 4,3, 9.4, and 5 percent for 909 stent patients, 652 percutaneous coronary angioplasty (PTCA) patients, 288 coronary artery bypass graft (CABG; without internal mammary grafting), and 812 CABG (with internal mammary grafting) patients, respectively [31]. At two years, all-cause survival was 83, 82, 74, and 83 percent for the stent, PTCA, CABG (without internal mammary grafting), and CABG (with internal mammary grafting) groups, respectively.

Compared with PTCA, the relative risk of death or acute MI for stent, CABG (without internal mammary grafting), and CABG (with internal mammary grafting) was 0.90, 0.80, and 0.57 (95% CI 0.42-0.76), respectively. Thus, similar long-term survival has been reported with surgical and percutaneous techniques, with the best survival being observed with CABG with an internal mammary graft. (See "Coronary artery bypass graft surgery: Graft choices".)

In one study of nearly 3000 kidney transplant recipients at one institution, survival of the 83 who required either bypass surgery or angioplasty was 89, 77, and 65 percent at one, three, and five years postprocedure, respectively [32].

De novo heart failure, a common condition among patients after kidney transplantation, is associated with poor survival. Based upon registry data from the United States Renal Data System (USRDS), the onset of heart failure increased the risk of death (adjusted HR [aHR] 2.6, 95% CI 2.4-2.9) and death-censored graft failure (aHR 2.7, 95% CI 2.4-3.0) [14]. Similarly, the development of atrial fibrillation increases the risk of death (aHR 3.2, 95% CI 2.9-3.6) and death-censored graft failure (aHR 1.9, 95% CI 1.6-2.3) [33].

Diabetes mellitus — Survival of patients with diabetes after kidney transplantation (75 to 80 percent at five years) is lower than that reported in patients without diabetes [34,35]. However, these results, due largely to extrarenal vascular disease, are still markedly better than those seen with dialysis, where the five-year patient survival rate is approximately 30 percent. (See "Kidney transplantation in diabetic kidney disease".)

Overall immunosuppression — The level of overall immunosuppression used for induction therapy, maintenance therapy, and the treatment of acute rejection episodes is a major risk factor for posttransplant infection, rather than the use of a specific immunosuppressive agent. Since infections are the leading cause of mortality in the early posttransplant period, infection and allograft dysfunction caused by rejection are closely interrelated through the use of immunosuppressive therapy [36,37]. (See "Kidney transplantation in adults: Induction immunosuppressive therapy" and "Kidney transplantation in adults: Maintenance immunosuppressive therapy".)

Allograft function — Several studies have shown that graft function is also associated with patient survival [38-41]. In a retrospective study of nearly 600 recipients of first deceased-donor allografts, significantly increased mortality was observed in patients with a primary nonfunctioning graft (ie, a graft that never functions) compared with those with less severe graft dysfunction (45 versus 20 percent at six years) [38]. The predominant cause of death was cardiovascular disease. (See "Kidney transplantation in adults: Evaluation and diagnosis of acute kidney allograft dysfunction".)

Patient survival is high among those with persistent, long-term graft function. In one survey of over 86,000 patients, of whom nearly 18,500 died over a 10-year period, survival at 1, 5, and 10 years was 97, 91, and 86 percent, respectively, among those with continued kidney allograft function [39].

CAUSES OF DEATH — Atherosclerotic cardiovascular disease continues to be the overall major cause of death after kidney transplantation, especially in recipients with diabetes, whereas infection and malignancy are the major causes of death among recipients without diabetes [17]. The causes of death among transplant recipients have changed over time and vary with age [42,43]. In a single-center study, for example, cardiac disease, cancer, and stroke as causes of death increased from 9.6, 1.2, and 2.4 percent, respectively, for the period 1970 to 1979 to 30.3, 13.2, and 8 percent for 1990 to 1999 [43].

In addition, death from cardiovascular disease is much less common among younger than older individuals [44]. Among prevalent transplant patients from 1994 to 1996, the following were the percentage of deaths due to the most significant life-threatening disorders:

All cardiac causes accounted for 18, 33, and 37 percent of deaths for those aged 0 to 19, 20 to 44, and 45 to 64, respectively.

Infection accounted for 25, 17, and 19 percent, respectively.

Malignancy accounted for 16, 8, and 11 percent, respectively.

Other known causes accounted for 41, 24, and 18 percent, respectively.

ESTIMATED POSTTRANSPLANT SURVIVAL — When a candidate is offered a kidney for transplant, available information about the candidate at the time of the organ offer will be used by the United Network for Organ Sharing (UNOS) to determine the candidate's estimated posttransplant survival (EPTS) score. This is for the purpose of allocating the organ. Patients with the most favorable EPTS score are allocated the best quality allografts that will provide the optimal long-term outcomes. The calculation for the EPTS score is based on four factors:

Candidate age

Length of time on dialysis

Any prior organ transplant

Diabetes status

The 20 percent of adult candidates with the lowest EPTS score are eligible to receive priority for kidneys from the highest-quality donors (as defined by Kidney Donor Profile Index [KDPI] scores in the top 20 percent) [45]. (See "Kidney transplantation in adults: Organ sharing", section on 'National deceased-donor kidney allocation policy'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Kidney transplant (The Basics)" and "Patient education: Planning for a kidney transplant (The Basics)")

SUMMARY

Overview – Kidney transplantation is the treatment of choice for selected patients with end-stage kidney disease (ESKD). A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients when compared with maintenance dialysis. (See 'Introduction' above.)

Patient survival in adult kidney transplant recipients

Short- and long-term survival rates – Both short- and long-term patient and graft survival rates among adult kidney transplant recipients have improved over time (figure 1 and figure 2). These improvements in long-term outcomes have been attributed to multiple factors, including lower rates of acute rejection, better pretransplant crossmatch techniques, judicious use of kidney paired donation (KPD) transplants for patients with incompatible living donors, surveillance for viral infections, and effective antiviral prophylaxis. (See 'Short- and long-term survival rates' above.)

Survival compared with dialysis – Studies comparing patients accepted for kidney transplantation who have undergone transplant surgery with those accepted for transplantation but who have not yet received a kidney allograft (ie, patients on dialysis who are on the transplant waiting list) have found that patient survival is overall better with kidney transplantation than with dialysis. (See 'Survival compared with dialysis' above.)

Survival compared with general population – Although transplantation confers the highest survival benefit among all of the different kidney replacement therapies, kidney allograft recipients still have a high mortality rate compared with population controls. (See 'Survival compared with general population' above.)

Factors that affect survival – Posttransplantation survival rates vary based upon the source of the allograft, recipient and donor age, and the presence and severity of comorbid conditions. Other factors that may contribute to survival rates include sex, race, and degree of immunosuppression. (See 'Factors that affect patient survival' above.)

Causes of death – Atherosclerotic cardiovascular disease is the major cause of death after kidney transplantation, especially in recipients with diabetes, whereas infection and malignancy are the major causes of death among recipients without diabetes. The causes of death among transplant recipients have changed over time and vary with age. (See 'Causes of death' above.)

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Topic 7347 Version 29.0

References

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