Death after graft loss: an important late study endpoint in kidney transplantation

Traditional study endpoints utilized in renal transplantation have included graft survival, and death with a functioning graft. We analyzed the risk factors for death after allograft loss (DAGL) among a total of 78564 primary renal transplants reported to the United States Renal Data System (USRDS) from 1988 to 1998. Cox models were used to investigate risk factors for DAGL. Of 15528 deaths, 10816 occurred before, and 4712 occurred after graft loss. Overall annual adjusted death rates were more than 3-fold higher after graft loss as compared to before graft loss (9.42% vs. 2.81%). By Cox model, dialysis for more than 2 years was associated with a more than 2-fold relative risk for DAGL (RR = 2.2, Cl = 1.88-2.53), while transplant time was not associated with DAGL. Infection related graft losses showed a strong association with DAGL (RR = 1.64, Cl = 1.31-2.07). Acute rejection and thrombosis as causes of graft loss were also significantly associated with the risk for DAGL (RR = 1.35, Cl = 1.23-1.47 and RR = 1.39, Cl = 1.39). Patient survival after graft loss is poor. The lack of association between DAGL and transplant time, as opposed to the strong relation to pretransplant dialysis time, would suggest the adverse effects of previous uremia-mediated damage may be contributing to this phenomenon, along with the adverse effects of loss of renal function.