Abstract
ObjectivesEnd-stage renal disease (ESRD) patients are at an increased risk of needing total joint arthroplasty (TJA); however, both dialysis and renal transplantation might be potential predictors of adverse TJA outcomes. For dialysis patients, the high risk of blood-borne infection and impaired muscular skeletal function are threats to implants’ survival, while for renal transplant patients, immunosuppression therapy is also a concern. There is still no high-level evidence in the published literature that has determined the best timing of TJA for ESRD patients.MethodsA literature search in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to November 2019) was performed to collect studies comparing TJA outcomes between renal transplant and dialysis patients. Two reviewers independently conducted literature screening and quality assessments with the Newcastle-Ottawa Scale (NOS). After the data were extracted, statistical analyses were performed.ResultsCompared with the dialysis group, a lower risk of mortality (RR = 0.56, Cl = [0.42, 0.73], P < 0.01, I2 = 49%) and revision (RR = 0.42, CI = [0.30, 0.59], P < 0.01, I2 = 43%) was detected in the renal transplant group. Different results of periprosthetic joint infection were shown in subgroups with different sample sizes. There was no significant difference in periprosthetic joint infection in the small-sample-size subgroup, while in the large-sample-size subgroup, renal transplant patients had significantly less risk (RR = 0.19, CI = [0.13, 0.23], P < 0.01, I2 = 0%). For dislocation, venous thromboembolic disease, and overall complications, there was no significant difference between the two groups.ConclusionTotal joint arthroplasty has better safety and outcomes in renal transplant patients than in dialysis patients. Therefore, delaying total joint arthroplasty in dialysis patients until renal transplantation has been performed would be a desirable option. The controversy among different studies might be partially accounted for that quite a few studies have a relatively small sample size to detect the difference between renal transplant patients and dialysis patients.
Highlights
Patients with end-stage renal disease (ESRD) are at an increased risk of osteonecrosis and osteoarthritis stemming from renal osteodystrophy, steroid use, amyloid deposition, and immunosuppressive therapy after renal transplant, which makes this population more likely to require total joint arthroplasty (TJA) [1,2,3,4,5]
Woods et al [10] published the first report of a successful total hip arthroplasty (THA) in a renal transplant patient treated with cemented Charnley implants and without complications at 26 months of follow-up
The first longterm follow-up study of THAs in renal transplant patients was reported by Cheng et al [12]; with a minimum of 10 years of follow-up, they published that 78% of prostheses survived and good outcome scores were maintained with minimal complications
Summary
Patients with end-stage renal disease (ESRD) are at an increased risk of osteonecrosis and osteoarthritis stemming from renal osteodystrophy, steroid use, amyloid deposition, and immunosuppressive therapy after renal transplant, which makes this population more likely to require total joint arthroplasty (TJA) [1,2,3,4,5]. Woods et al [10] published the first report of a successful total hip arthroplasty (THA) in a renal transplant patient treated with cemented Charnley implants and without complications at 26 months of follow-up. The first longterm follow-up study of THAs in renal transplant patients was reported by Cheng et al [12]; with a minimum of 10 years of follow-up, they published that 78% of prostheses survived and good outcome scores were maintained with minimal complications. The majority of experts supported that TJA should be performed after renal transplant, instead of replacing the joint while patients are on dialysis [16]. This recommendation was based on limited data
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