| Abstract|| |
Renal transplantation is the most effective treatment modality for end-stage renal failure. According to the Ministry of Health Organ Transplant Registration System, despite the presence of 14,936 renal transplant recipients in Turkey, there are not enough data about the prognosis of these patients. Therefore, we aimed to ascertain the rate of patients returning to hemodialysis (HD) due to nonfunctioning graft in our country. One thousand four hundred and ninety-eight (males: 826, females: 672) HD patients who undergo HD at 22 HD centers in total, from different geographical regions to represent our country were examined retrospectively. The informations were obtained from patient registry files and anamnesis which were in HD centers. The number of patients returning to HD due to the loss of graft function was 77 (males: 56, females: 21). Eleven of the patients had transplantation from cadavers (14%) and 66 from living donors (86%). Prevelance of patients, who return to HD after the failure of renal transplantation, between HD patients was 5.1. The mean duration of return to HD after renal transplantation was 6.7 ± 5.9 years for all patients. There was no significant difference in the duration without HD after transplantation between two groups when cadaveric and living donor transplants were compared (P = 0.759). There was no statistically significant difference in duration without HD after transplantation between patients receiving HD treatment before transplantation and preemptive transplant (P = 0.212). The prevelance of patients, who return to HD due to nonfunctioning graft among HD patients was 5.1. The duration without HD were similar after transplantation from both cadavers and living donors. The duration without HD was found longer among those who were operated before 2000.
|How to cite this article:|
Altun I, Selcuk N Y, Baloglu I, Turkmen K, Tonbul H Z. The characteristics of patients returning to hemodialysis due to nonfunctioning graft in Turkey. Saudi J Kidney Dis Transpl 2019;30:1052-7
|How to cite this URL:|
Altun I, Selcuk N Y, Baloglu I, Turkmen K, Tonbul H Z. The characteristics of patients returning to hemodialysis due to nonfunctioning graft in Turkey. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Nov 21];30:1052-7. Available from: http://www.sjkdt.org/text.asp?2019/30/5/1052/270260
| Introduction|| |
Renal transplantation is the most effective treatment modality for end-stage renal disease. However, in some patients, graft loss might occur, in the early or late period after transplantation and these patients have to be back on the dialysis. All these patients would have received immunosuppressive therapy and are at risk for many medical complications compared to routine dialysis patients. The United States Renal Data System (USRDS) database show that mortality is primarly due to cardiac (36%) and infections complications (17%) in patients who have been reinitiated on dialysis after graft failure.
The five-year graft survival after cadaveric and living donor kidney transplantation has been reported as 66% and 67%, respectively. According to the USRDS database annual graft loss rate was 4% in renal transplantation patients. In another study conducted by examining the transplantation database (UNO/ OPTN) of the same country, it was found that allograft insufficiency developed in a significant proportion of patients in the late period of transplantation.
According to international studies, when the hemodialysis (HD) patients are examined, the number of patients who gets reiniated on dialysis after renal transplantation failure have been increasing. Similary, according to USRDS database also, the number of patients who return to HD after renal transplant failure have been increasing in the past 20 years. However, the ratio is stable around 4%–5%. Similar findings may also exist in Europe, but there is no such calculations in the database of the European Kidney Society.
According to the Ministry of Health organ transplant registration system, there were 14,936 patients who had underwent renal transplantation in Turkey from 2011 to the end of 2015. On the other hand, according to Turkish Society of Nephrology’s 2015 registry report, the number of patients who were monitored with functional graft was 6515. Moreover, there is no information about remaining patients. According to registry of the Turkish Society of Nephrology between 2011 and 2015, yearly rates of mortality and return to dialysis ranged from 1.7% to 4.83% and 1.31% to 3.5%, respectively. However, there have been no long-term data of these patients. Therefore, we aimed to reveal the prevalence of patients returning to HD due to nonfunctioning graft in our country.
| Subjects and Methods|| |
The study protocol was approved by the Medical Ethics Committee of Necmettin Erbakan University (School of Medicine, Konya, Turkey). Written informed consent was obtained from patients.
For the results of our study to represent all of our country, HD units were selected from different geographical regions. A total of 1498 (males: 826, females: 672) HD patients who undergo HD at 22 different HD centers were included in the study.
Patients were examined retrospectively from patient registry files of HD centers. The information was entered into a previously prepared form. The name of the HD center, the total number of HD patients, the number and gender of patients who had previously undergone renal transplantation, and informations related to transplantation were recorded in the form.
| Statistical Analysis|| |
The statistical analysis was carried out by the Statistical Package for the Social Sciences for Windows version 18.0 (SPSS Inc., Chicago, IL, USA). Data were expressed as the mean ± standard deviation (SD), with a significance level of Ρ <0.05. The normal distribution suitability of the variables was examined by the Kolmogorov–Smirnov/Shapiro–Wilk test. The mean value ± SD for normal distribution data and the median (minimum to maximum) value for nonnormal distribution data were used. The Mann–Whitney U-test was used to show the difference between two independent groups without normal distribution. The Kruskal–Wallis test was used to show the difference between more than two groups of values and the Pearson Chi-square statistical test was used to compare categorical data.
| Results|| |
In this study, 1498 (male: 826, female: 672) adult HD patients were examined in a total of 22 HD centers. A total of 77 patients (male: 56, K: 21) were found to have undergone renal transplantation which were performed between 1979 and 2014. The prevalence of patients, who got reiniated dialysis after transplantation, was found to be 5.1%. Eleven of these patients were transplanted from cadavers (14%) and 66 were from living donors (86%). When living donor transplants were examined, mostly, mothers kidneys (33%) were used for graft.
Regardind vintage of HD prior to transplantation, it was found that they had median of 12 months (1–120) in all patients, 28 months (6–20) in cadaveric transplantations and nine months (1–84) in living donor transplantations. The mean duration of return to HD after renal transplantation was 6.7 ± 5.9 years for all patients. The longest duration without HD after transplantation was 32 years. The mean duration without HD were in transplantation with cadaveric and living donor 8.8 ± 8.7 years, 6.3 ± 5.3 years, respectively. There was no significant difference in duration without HD after transplantation between two groups when cadaveric and living donor transplants were compared [Table 1] (P = 0.759). Four of the patients, who were transplanted from living donor, returned to HD within the same year.
|Table 1: Duration without hemodialysis after renal transplantation (median).|
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Patients were divided into two subgrups (Group 1: year of surgery before 2000, n = 11 and Group 2: year of surgery from 2000, n = 66) according to the year of surgery. The duration without HD after transplantation was significantly higher in patients who had surgery before 2000 (Group 1) than in patients who underwent surgery >2000 (Group 2) [Table 2] (P= 0.001).
|Table 2: Duration without hemodialysis after renal transplantation according to year of surgery.|
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Graft nephrectomy was performed in 11 (14%) of patients with graft loss. Reasons for surgery were infection, hyperacute cellular rejection, and other causes, 55%, 9%, and 14%, respectively.
The duration without HD after transplantation in 10 patients who had not undergone HD (preemptive) before transplantation was 4.40 ± 3 years. On the other hand, in 67 patients who had undergone HD prior to transplantation, the duration without HD was 7.06 ±6.1 years. There was no statistically significant difference in duration without HD after transplantation between patients receiving HD treatment before transplantation and preemptive transplant (P = 0.212) [Table 3].
|Table 3: Duration without hemodialysis after renal transplantation according to pretransplant hemodialysis treatment.|
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The duration without HD after transplantation were six (1–32) years in 41 patients who had undergone HD for one year, six (1–24) years in 21 patients who had undergone HD for one to five years, two (1–18) years in five patients who had undergone HD for five to 10 years; there was no significant difference between these three groups [Table 4].
|Table 4: Duration without hemodialysis after renal transplantation according to the duration of hemodialysis before transplantation.|
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| Discussion|| |
The main finding of this study was that the prevelance of patients, who return to HD after the failure of renal transplantation, between HD patients was 5.1. Our study is the first study to examine prevelance of patients returning to HD and factors of affecting duration without HD after transplantation in Turkey.
According to international studies, when the HD patients are examined, the rates of patients returning to HD after renal transplantation failure are increasing steadily. While in Canada and Australia, this ratio was between 2% and 3%, according to the USRDS, this ratio was between 4% and 5%. In Europe and in our country, there is no previous work on this issue. In this study, we found the prevalence of patients who got reiniated to dialysis after transplantation in our country is higher than international studies in Canada and Australia, but according to the USRDS database our results was similar to the USA. This ratio is not negligible in our country and it is necessary to investigate carefully the causes that may cause graft loss in patient follow-ups and to prevent mortality and morbidity increase with follow-up.
Arend et al reported that graft failure is more frequent in cadaveric transplantations and mortality increase after graft failure. Similarly, in another study, the one-year survival rates of grafts in living donor transplants were found to be higher than cadaveric transplants. In our study, there was no significant difference in duration without HD after transplantation between the two groups when cadaveric and living donor transplants were compared. The fact that the number of cadaveric transplants in our country is fewer than the western countries may be leading to such a result.
In a study done by Cosio et al determined that, increased duration of dialysis before transplantation causes increased of infection, left ventricular hypertrophy, and increased prevalence of cardiomegaly. In conclusion, the prolongation of the duration of dialysis before renal transplantation was associated with a decrease in the survival of transplant recipients. However, in our study, there was no statistically significant difference in duration without HD after transplantation between patients receiving HD treatment before transplantation and preemptive transplant (P = 0.212). In addition; there was no effect on the duration without HD after transplantation time of HD duration.
In 2014, Abouchacra et al found that graft nephrectomy was performed in 27% of patients returning to HD after graft loss. Moreover, they reported that while the hospitalization rates were higher, the survival was better in these patients. According to the USRDS database after graft loss, graft nephrectomy was performed in 31.5% of patients. In addition, in the same database, it has been reported that removal of the chronic inflammatory condition and need for immunosuppresion, due to graft nephrectomy is beneficial on patient survival. In a study done by Szabó et al, 37 grafts which performed nephrectomy were examined histologically. In all cases, findings of chronic rejection such as chronic interstitial mono-nuclear cell infiltration, vasculer fibrosis and interstitial fibrosis were detected. In our study, graft nephrectomy was performed in 11 (14%) of patients with graft loss. Reasons for nephrectomy were infection, hyperacute cellular rejection and other causes, 55%, 9%, 14%, respectively.
A number of studies have shown that dialysis reinitation after graft failure increasing steadily. Pham et al reported that the number of patients returning to dialysis after graft failure has increased twofold between 1988 and 2010. Similarly, in our study, patients who had been transplanted after the year 2000 and returned to HD were six times more than patients who had been transplanted before the year 2000. In other words, a larger proportion of patients entering HD after transplantation in our country and worldwide, are those who have had more recent transplant operations. These findings may suggest that failure in patients’ follow-ups is increasingly higher than in the past and that measures should be taken in this regard.
Our study has several limitations. First, all HD patients in Turkey have not been examined into study. Second, number of cadaveric transplantsin our country fewer than Western countries. Therefore, some results in our study may be differ from the Western countries.
In conclusion, we found the prevelance of patients, who return to HD after the failure of renal transplantation, between HD patients was 5.1 in our country. The duration without HD after transplantation; in transplantation from cadavers and living donors, were similarly. The duration without HD was found longer who were operated before 2000. The duration of pretransplantation HD did not affect the prognosis.
Conflict of interest: None declared.
| References|| |
Gill JS, Abichandani R, Kausz AT, Pereira BJ. Mortality after kidney transplant failure: The impact of non-immunologic factors. Kidney Int 2002;62:1875-83.
Cecka JM. The UNOS scientific renal transplant registry – Ten years of kidney transplants. Clin Transpl 1997:1-4.
Collins AJ, Foley R, Herzog C, Chavers B, Gilbertson D, Ishani A, et al. Excerpts from the United States Renal Data System 2007 Annual Data Report. Am J Kidney Dis 2008;51:S1-320.
Hariharan S, Johnson CP, Bresnahan BA, Taranto SE, McIntosh MJ, Stablein D. Improved graft survival after renal transplantation in the United States, 1988 to 1996. N Engl J Med 2000;342:605-12.
Perl J, Bargman JM, Davies SJ, Jassal SV. Clinical outcomes after failed renal transplantation-does dialysis modality matter? Semin Dial 2008;21:239-44.
Collins AJ, Foley RN, Herzog C, et al. us renal data system 2010 annual data report. Am J Kidney Dis 2011;57:A8, e1-526.
Seyahi N, Altıparmak MR, Süleymanlar G. Current Status of Renal Replacement Therapy in Turkey: A Summary of Turkish Society of Nephrology 2014 Annual Registry Report; 2015.
McDonald S, Hurst K. Thirty Fourth Annual Report. Australian & New Zealand Dialysis & Transplant Registry Report. Adelaide, South Australia; 2011. p. 4-44.
Molnar MZ, Ichii H, Lineen J, et al. Timing of return to dialysis in patients with failing kidney transplants. Semin Dial 2013;26:667-74.
Arend SM, Mallat MJ, Westendorp RJ, van der Woude FJ, van Es LA. Patient survival after renal transplantation; more than 25 years follow-up. Nephrol Dial Transplant 1997; 12: 1672-9.
Cosio FG, Alamir A, Yim S, et al. Patient survival after renal transplantation: I. The impact of dialysis pre-transplant. Kidney Int 1998;53:767-72.
Abouchacra S, Chaaban A, Saleh A, et al. Patients returning to dialysis after failed kidney transplant: How do they fare? A gulf perspective. Open J Intern Med 2014;4:82.
Ayus JC, Achinger SG, Lee S, Sayegh MH, Go AS. Transplant nephrectomy improves survival following a failed renal allograft. J Am Soc Nephrol 2010;21:374-80.
Szabó RP, Klenk N, Balla J, et al. Prognosis of dialysed patients after kidney transplant failure. Kidney Blood Press Res 2013;37:151-7.
Pham PT, Everly M, Faravardeh A, Pham PC. Management of patients with a failed kidney transplant: Dialysis reinitiation, immunosuppression weaning, and transplantectomy. World J Nephrol 2015;4:148-59.
Department of Internal Medicine, Division of Nephrology, Necmettin Erbakan University, Konya
[Table 1], [Table 2], [Table 3], [Table 4]