Inequalities in outcomes after kidney transplant failure in the UK

Failing transplant management is an international research priority. The Failing Kidney Transplant Outcomes Registry Analysis (FAKTOR) is investigating management and outcomes of kidney transplant failure in the UK.

A retrospective cohort analysis using UK Renal Registry data on adults (≥18 years) with kidney transplant failure (eGFR < 15ml/min/1.73m2) between 01/2012-12/2021. Treatment status was determined each year post-failure as the first status recorded of: i) re-transplantation, ii) haemodialysis (HD), iii) peritoneal dialysis (PD), iv) death; those alive without changing Kidney Replacement Therapy (KRT) modality classed as v) alive without new KRT, subclassified as vi) managed conservatively if eGFR < 7.5ml/min/1.73 m2 with no future dialysis. Treatment status was determined by one-year post-failure and reported by: age, sex, ethnicity, socioeconomic group, primary renal disease (PRD) and centre type (transplanting/non-transplanting). When applicable, last eGFR pre-dialysis was recorded. Regression models investigated the relationship between patient characteristics and centre type with outcomes: i) treatment status by one-year and ii) pre-dialysis eGFR.

We included 5447 patients. By one-year, 47.8% first received HD and 5.2% were pre-emptively re-transplanted. Black and Asian people were less likely to be re-transplanted than White people (Black Relative Risk Ratio (RRR) 0.41, 95% CI 0.20-0.87. Asian RRR 0.57, 0.34-0.96). Males were more likely to be re-transplanted (RRR 1.39, 1.06-1.81) and to receive HD (RRR 1.68, 1.47-1.92). Each quintile increase in deprivation was associated with a 22% lower re-transplantation likelihood (RRR 0.78, 0.71-0.86). Diabetic PRD was associated with higher mortality (RRR 1.97, 1.34-2.88) relative to glomerulonephritis. Median pre-dialysis eGFR was 9.6 ml/min/1.73 m2 (IQR 7.7-11.7) and 7.1% higher in non-transplanting compared with transplanting centres (+7.1%, + 2.6% to +11.9%).

This first nationwide description of outcomes following kidney transplant failure in the UK highlights strong evidence of pre-emptive re-transplantation inequalities, favouring White people, those in less deprived areas and males.