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Posttransplant deaths and factors that influence the mortality rate in North American children
A Tejani1, E K Sullivan, S Alexander
1NAPRTCS Clinical Coordinating Center, SUNY Health Science Center at Brooklyn 11203-2098.
Insights
Pediatric kidney transplant recipients face high mortality, primarily from infection and cardiovascular issues. Young recipient age is the biggest risk factor for death after transplantation.
Area of Science:
- Nephrology
- Pediatric Transplantation
- Immunology
Background:
- Pediatric renal transplantation is a critical treatment for end-stage renal disease.
- Understanding post-transplant mortality is essential for improving patient outcomes.
Purpose of the Study:
- To identify risk factors for mortality in pediatric kidney transplant recipients.
- To analyze the impact of donor type, recipient age, and specific complications on survival.
Main Methods:
- Retrospective analysis of 2457 pediatric kidney transplant recipients from the North American Pediatric Renal Transplant Cooperative Study registry.
- Follow-up for 5481 patient-years, with observation of 136 deaths.
- Cox proportional hazards model used to assess risk factors.
Main Results:
- Overall mortality rate was 24.8 deaths per 1000 patient-years, primarily due to infection (40%) and cardiovascular causes (21%).
- Cadaveric donor source (6.7%) and younger recipient age (0-1 years: 17.5%) were associated with significantly higher mortality.
- Acute tubular necrosis (ATN) and graft failure within 30 days (GF30) markedly increased mortality risk (RR 3.1 for ATN, 6.4 for GF30).
- Specific renal diseases like oxalosis and congenital nephrotic syndrome also showed high mortality rates.
Conclusions:
- Recipient age is the primary determinant of mortality after pediatric renal transplantation.
- Reducing ATN and preventing early graft failure through improved matching techniques are crucial for improving survival rates in this vulnerable population.
Abstract:
Of 2457 patients in the North American Pediatric Renal Transplant Cooperative Study registry who were followed for 5481 patient-years after the index transplantation, we observed 136 deaths, for an average annual rate of 24.8 deaths per 1000 patient-years. Death resulted primarily from infection (n = 55, 40%), cardiovascular causes (n = 28, 21%), hemorrhage (n = 16, 12%), and malignancies (n = 9, 7%). Cadaver-donor source was associated with greater mortality (6.7%) than a living-donor source (4.0%) (P < 0.005). Recipients aged 0-1, 2-5, 6-12, and 13-17 years old had mortality rates of 17.5, 8.0, 3.6, and 4.5%, respectively (P < .001). Mortality rates increased substantially when examined by recipient and cadaver donor ages (mortality rates of up to 45%), the greater the concordance between young donor and recipient ages. Interestingly, acute tubular necrosis and graft failure less than 30 days after transplantation (GH30) were each associated with markedly elevated mortality rates. (The risk ratio for ATN was 3.1 [P < 0.001] and for GF30 it was 6.4 [P < 0.001].) Mortality after transplantation was also affected by the underlying renal disease, with high mortality rates observed for oxalosis (n = 21, 33.3%), congenital nephrotic syndrome (n = 79, 15.2%), pyelo/interstitial nephritis (n = 54, 11.1%), and Drash syndrome (n = 14, 21.4%). When the joint effect of these risk factors was examined in a Cox proportional hazards model, young recipient age (0-1 years old) and GF30 were significant (P < .001) risk factors of mortality for recipients of living-donor organs. For recipients of cadaver kidneys, young recipient age--0-1 years old (P < .001) and 2-5 years old (P = .002)--ATN (P = .029), and GF30 (P < .001) were all significant risk factors. Recipient age is the major determinant of increased mortality after renal transplantation. Avoidance of acute tubular necrosis by reducing cold time and preventing early graft failure by better matching techniques in this vulnerable population may improve the mortality rate.