Abstract
An understanding of long-term outcomes for kidney transplant(KTx) recipients who survive with graft function beyond a specific time posttransplant is the first step in creating protocols to optimize care for current and improve outcomes for future recipients. We studied 831KTx recipients-580 living donor(LD); 251 deceased donor(DD)—with graft survival(GS) >20 years. For primary LD recipients, 25-year patient survival(PS) was 83%; 35-year, 59%. Their 25-year death-censored graft survival(DCGS) was 89%; 35-year, 72%. DD recipients had lower PS(P<0.01), DCGS(P<0.01). After 20 years, two major causes of graft loss(GL) were death with function(DwF)(58%, LD; 58%, DD) and interstitial fibrosis and tubular atrophy(IFTA)(22%, LD; 23%, DD). Two major causes of DwF were cancer(31%, LD; 31%, DD) and cardiovascular disease(CVD)(19%, LD;17%, DD). Per multivariate analysis(MVA), risk factors for GL after 20 years in pre–calcineurin inhibitor(CNI) era were human leukocyte antigen(HLA) mismatches >3 antigens, pretransplant type 1 diabetes mellitus(DM1); in CNI era, a history of rejection, female gender. New comorbidities after 20 years were common: CVD(13%, non-DM1;18%, DM1), infections(27%, non-DM1;37%, DM1), 20-29 years posttransplant. Cancer after 20 years included: nonmelanotic skin cancer,22%; solid organ,7%; post-transplant lymphoproliferative disease(PTLD),2%. To improve long-term outcomes, clinical trials on prevention, recognition, and treatment of new comorbidities are needed.
Highlights
In the history of clinical transplantation, the rates of 1-year patient survival (PS) and graft survival (GS) were low.In the 1960s, for deceased donor (DD) kidney transplant recipients in the United States, 1-year PS was 55%; GS, 35% [1].Currently, with advances in immunosuppression, antimicrobial management, pretransplant histocompatibility testing, and pre- and posttransplant care, both short- and intermediate-term outcomes (1 to 10 years posttransplant) have improved, and more recipients are surviving long-term [2, 3].Numerous factors—e.g., end-stage renal disease (ESRD)or morbidity pretransplant, prolonged exposure to immunosuppression posttransplant—affect long-term PS, GS, and development of comorbidities
Recipient and donor characteristics Of the 3,802 transplants (1,937 living donor (LD), 1,865 DD) from June 7, 1963 through September 15, 1993, a total of 836(22%) (583 LD, 253 DD) grafts had GS of at least 20 years. (Of those 831 recipients, 5 had undergone 2 transplants, each lasting ≥20 years.) Only 65(8%) of the 831 recipients were subsequently lost to follow-up: of these, 38 of them lost their graft with the date and cause entered into the database); the other 27 are presumed to still have graft function
We showed that the major causes of graft loss after 20 years were similar for LD vs. DD recipients, for primary vs. retransplant recipients, for both immunosuppressive eras, and for each of the 5-year intervals (20 to 24 years, 25 to 29 years, 30 to 34 years, >34 years)
Summary
In the history of clinical transplantation (i.e., through the mid-1970s), the rates of 1-year PS and GS were low.In the 1960s, for DD kidney transplant recipients in the United States, 1-year PS was 55%; GS, 35% [1].Currently, with advances in immunosuppression, antimicrobial management, pretransplant histocompatibility testing, and pre- and posttransplant care, both short- and intermediate-term outcomes (1 to 10 years posttransplant) have improved, and more recipients are surviving long-term (i.e., with GS>10 years) [2, 3].Numerous factors—e.g., end-stage renal disease (ESRD)or morbidity pretransplant, prolonged exposure to immunosuppression posttransplant—affect long-term PS, GS, and development of comorbidities. In the history of clinical transplantation (i.e., through the mid-1970s), the rates of 1-year PS and GS were low. In the 1960s, for DD kidney transplant recipients in the United States, 1-year PS was 55%; GS, 35% [1]. With advances in immunosuppression, antimicrobial management, pretransplant histocompatibility testing, and pre- and posttransplant care, both short- and intermediate-term outcomes (1 to 10 years posttransplant) have improved, and more recipients are surviving long-term (i.e., with GS>10 years) [2, 3]. Morbidity pretransplant, prolonged exposure to immunosuppression posttransplant—affect long-term PS, GS, and development of comorbidities. As long-term recipients age, they can develop age-related morbidities that are not necessarily related to pretransplant conditions or to immunosuppression.
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