#1849 Returning to dialysis after kidney transplant failure: preliminary findings of a multi-centre database
Authors: Ye Xiaoling (Janice) , Shivakumar Oshini , Larkin John , Kotanko Peter , Hippen Benjamin , Guinsburg Adrian , Raimann Jochen , Ashby Damien , Tam Frederick , Ashrafian Hutan , Darzi Ara , Duncan Neill 
Published: May 2024

Abstract

Background and Aims
Kidney transplant failure contributes to a considerable proportion of new dialysis starters. In some centres there are dedicated clinics for patients with failing kidney transplants, however, the specific needs of patients with dialysis after graft loss (DAGL) may be lost in the non-specific clinical review practiced in the general dialysis community. This study examines the mortality and morbidity risk in patients returning with DAGL and compares it to transplant-naïve (T-N) dialysis starters, to determine if the former warrant a more specialised approach.

Method
This is a retrospective observational study of mortality in all adult patients who started dialysis treatments in Fresenius Medical Care (North America, Latin America, Europe, Middle East, Africa, and Asia Pacific) from 1st January 2018 to 31st March 2021, were identified in the Apollo Dial DB dataset. DAGL was identified from the ICD-10 codes ‘Kidney transplant failure’, ‘Unspecified complication of kidney transplant’ and ‘Other complication of kidney transplant’ at dialysis start. The T-N control group had not previously received a kidney transplant and had not received immunosuppressive medication during the first six months of dialysis start.
The first six months on dialysis were defined as baseline, months 7 to the end of year 5 were defined as the follow-up period. All-cause mortality was recorded during follow-up. Cox proportional hazards models were applied to explore the association between DAGL and all-cause mortality.

Results
A total of 360 469 dialysis starter patients from 41 countries were included in the analysis. 10 010 patients had DAGL and were compared with 350 459 in the T-N control group. In univariate analysis, DAGL patients were significantly younger in all age categories and had a higher proportion of male sex. Serum creatinine, ferritin, phosphate and neutrophil-to-lymphocyte ratio were higher in the DAGL group. Haemoglobin was lower in the DAGL group (Table 1).
In the Cox proportional model adjusted for age, gender, and other laboratory and clinical markers, patients with DAGL had an equivalent survival probability compared with T-N dialysis starters (HR: 0.93, 95% CI: 0.86, 1.02) (Table 2).

Conclusion
DAGL patients appeared to have an increased mortality compared to T-N dialysis starters historically in the literature. Our large and recent study is in line with other recent publications suggesting a more equivalent survival in the two groups. Our results are compatible with younger patients receiving kidney transplantation early in their renal replacement therapy journey, thus constituting a significant proportion of DAGL patients. We posit that DAGL patients may start dialysis at a lower level of renal function, with higher levels of inflammation. Our analysis is preliminary and limited, not fully accounting for confounding factors. Future analysis of this large and well recorded dataset will allow us to examine these interesting associations and design a more specialised management approach to DAGL more closely.