Late renal transplant failure: An adverse prognostic factor at initiation of peritoneal dialysis

Background., Early renal transplant failure necessitating a return to dialy sis has been shown to be a poor prognostic factor for survival. Little is k nown about the outcome of patients with late transplant failure returning t o dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients retu rning to dialysis. Objective: To determine whether patients with a failed renal transplant hav e an outcome different to those on dialysis who have never received a kidne y transplant. Setting: Peritoneal dialysis (PD) unit in a teaching hospital. Patients and Design: All failed renal transplant patients (fTx) in the Toro nto Hospital Peritoneal Dialysis program between 1989 and 1996 were identif ied. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was select ed because of the availability of well-documented patient archival material . The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, d eath, or until June 1998. Results:There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for t he increased total length of dialysis in fTx (mean 15 months). However, pos t-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome th an the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a muc h faster rate in fTx patients. The most dramatic difference was in survival . There were 3 deaths in the non-Tx group and 12 in the fTx group (p < 0.01 ). The mean age at time of death in the fTx group was 47.5 years. Deaths we re due mainly to gram-negative peritonitis and cardiovascular disease. Conclusions: We conclude that late failed renal transplant patients startin g dialysis are at increased risk of complications and have strikingly highe r mortality rates than non-Tx patients. A previously failed kidney transpla nt can be considered an adverse prognostic factor for patients commencing P D; these patients need to be closely monitored. Although this study was lim ited to PD patients, the same principles likely apply to fTx patients retur ning to any form of renal replacement therapy.