By Kristina Rebelo
SAN DIEGO -- October 30, 2009 -- While a higher residual native kidney function did not offer a significant decreased morbidity advantage in preemptive kidney transplantation, it was still associated with a lower risk of acute rejection and delayed graft function, and a lower risk of graft failure, in a subgroup analysis in patients with polycystic kidney disease (PKD).
The findings were presented by Basit Javaid, MD, Stanford Hospital & Clinics, Stanford University Medical Center, Palo Alto, California, during a news conference on October 29 here at the American Society of Nephrology (ASN) Renal Week 2009.
In order to compare post-transplant outcomes, all preemptive kidney transplant recipients in the United Network for Organ Sharing (UNOS) dataset who received first kidney transplant as a single organ between October 1987 and February 2009 were eligible for analysis.
Researchers used pretransplant kidney function assessment based on estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) formula. Analysis was restricted to patients with eGFR of <=20 mL/min/1.73 m2. Patients were divided into high-eGFR or low-eGFR groups, based on median MDRD eGFR value at transplantation.
"Preemptive [transplantation] is better without dialysis, with a 16% reduction in risk of death," stated Dr. Javaid. He pointed out that all the UNOS data was based on pretransplant kidney function, and that UNOS will not allow the listing of a patient whose kidney function is more than 20%.
The study demonstrated that, of the 25,748 adult patients who had received a first preemptive kidney transplant (median eGFR 9.95 mL/min/1.73 m2), the risks of recipient death, graft loss, and death-censored graft loss in the entire cohort were similar in both groups.
The high-eGFR group had lower odds of acute rejection at 6 months after transplant (odds ratio [OR] = 0.66; 95% confidence interval [CI], 0.59-0.74; P < .01). Patients in the high-eGFR group were also less likely to require dialysis in the first week of transplantation (OR = 0.65; 95% CI, 0.43-0.65; P < .01).
These patients avoided the morbidity associated with dialysis and dialysis-access procedures. Dr. Javaid noted that there were more diabetics in this group and that "the meat of the study was based on the level of kidney function before transplant."
In the subgroup analyses, Dr. Javaid reported that PKD patients who were in the high eGFR group had a lower risk for all-cause graft failure (HR = 0.75; 95% CI, 0.59-0.95; P = .02); as well as death-censored graft failure (HR = 0.69; 95% CI, 0.51-0.94; P = .02).
PKD patients also had lower odds of acute rejection (OR = 0.73; 95% CI, 0.56-0.92; P < .01) and delayed graft function (OR = 0.52; 95% CI, 0.35-0.78; P < .01).
"In our study [of PKD patients], a higher native kidney function did not offer a significant survival advantage, so the time of transplantation can be relatively flexible in terms of timing the surgery," said Dr. Javaid. "And it was associated with a lower risk of acute rejection and delayed graft function."
He concluded, "Based on these findings, we feel that patients and transplant experts anticipating a preemptive kidney transplant can wait for clinical indications to emerge without any significant loss of survival advantage associated with a preemptive transplant."
[Presentation title: Preemptive Kidney Transplant: Wouldn't Earlier Be Even Better? Abstract TH-PO1042]
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