Beyond the first posttransplant year, 3% of kidney transplants fail annually. In a prospective, multicenter cohort study, we tested the relative impact of early versus late events on risk of long-term death-censored graft failure (DCGF). In grafts surviving at least 90 days, early events (acute rejection [AR] and delayed graft function [DGF] before day 90) were recorded; serum creatinine (Cr) at day 90 was defined as baseline. Thereafter, a 25% rise in serum Cr or new-onset proteinuria triggered graft biopsy (index biopsy, IBx), allowing comparison of risk of DCGF associated with early events (AR, DGF, baseline serum Cr >2.0 mg/dL) to that associated with later events (IBx). Among 3678 patients followed for 4.7 ± 1.9 years, 753 (20%) had IBx at a median of 15.3 months posttransplant. Early AR (HR = 1.77, P <.001) and elevated Cr at Day 90 (HR = 2.56, P <.0001) were associated with increased risk of DCGF; however, later-onset dysfunction requiring IBx had far greater impact (HR = 13.8, P <.0001). At 90 days, neither clinical characteristics nor early events distinguished those who subsequently did or did not undergo IBx or suffer DCGF. To improve long-term kidney allograft survival, management paradigms should promote prompt diagnosis and treatment of both early and later events.
Bibliographical noteFunding Information:
This work was supported between 2005 and 2012 via a grant from the National Institutes of Health (5U01A1058013), and since 2013 by unrestricted grants from Astellas, Bristol-Myers Squibb, Novartis, Pfizer, and Sanofi-Aventis.
© 2017 The American Society of Transplantation and the American Society of Transplant Surgeons
- chronic allograft nephropathy
- clinical research/practice
- delayed graft function (DGF)
- kidney (allograft) function/dysfunction
- kidney transplantation/nephrology
- rejection: acute