Abstract
BackgroundImproved recognition of factors influencing graft survival has led to better short-term kidney transplant outcomes. However, efforts to prevent long-term graft decline and improve graft survival have seen more modest improvements. The adoption of electronic health records has enabled better recording and identification of donor-recipient factors through the use of modern statistical techniques. We have previously shown in a prevalent renal transplant population that episodes of rapid deterioration are associated with graft loss.MethodsEstimated glomerular filtration rates (eGFR) between 3 and 27 months after transplantation were collected from 310 kidney transplant recipients. We utilised a Bayesian approach to estimate the most likely eGFR trajectory as a smooth curve from an average of 10,000 Monte Carlo samples. The probability of having an episode of rapid deterioration (decline greater than 5 ml/min/1.73 m2 per year in any 1-month period) was calculated. Graft loss and mortality data was collected over a median follow-up period of 8 years. Factors associated with having an episode of rapid deterioration and associations with long-term graft loss were explored.ResultsIn multivariable Cox Proportional Hazard analysis, a probability greater than 0.8 of rapid deterioration was associated with long-term death-censored graft loss (Hazard ratio 2.17; 95% Confidence intervals [CI] 1.04–4.55). In separate multivariable logistic regression models, cytomegalovirus (CMV) serostatus donor positive to recipient positive (Odds ratio [OR] 3.82; 95%CI 1.63–8.97), CMV donor positive (OR 2.06; 95%CI 1.15–3.68), and CMV recipient positive (OR 2.03; 95%CI 1.14–3.60) were associated with having a greater than 0.8 probability of an episode of rapid deterioration.ConclusionsEarly episodes of rapid deterioration are associated with long-term death-censored graft loss and are associated with cytomegalovirus seropositivity. Further study is required to better manage these potentially modifiable risks factors and improve long-term graft survival.
Highlights
Improved recognition of factors influencing graft survival has led to better short-term kidney transplant outcomes
Data for every study participant were extracted from the Department of Health Informatics database, with manual record linkage to additional Electronic Health Record (EHR): graft survival was acquired from the UK Transplant Registry held by NHS Blood and Transplant; patient survival data were obtained from the Office for National Statistics
Patients were classified based on CMV serostatus: donor and recipient seronegative (D−/R−), donor seronegative and recipient seropositive (D−/R+), donor seropositive and recipient seronegative (D+/R−), and donor and recipient seropositive (D+/R+)
Summary
Improved recognition of factors influencing graft survival has led to better short-term kidney transplant outcomes. Efforts to prevent long-term graft decline and improve graft survival have seen more modest improvements. The last three decades have seen a remarkable improvement in renal transplant survival, a product of technological advances in surgical technique and medical care. In addition to improving graft survival, maintenance of transplant graft function, or glomerular filtration rate, is another key strategy to minimise the complications associated with advanced chronic kidney disease (CKD) and improve patient survival [1, 2]. Early outcomes after kidney transplantation have improved markedly over the last couple of decades, improvements in long-term outcomes have been much more modest [1, 5]. Potentially modifiable risk factors including cytomegalovirus (CMV) serostatus/mismatch are emerging as possible therapeutic targets [7]
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