Deaths over a period of up to 10 years post-transplantation (Tx) and the associated risk factors were examined in patients (pts) with protocol biopsies (total observation: 4805 patient-years).

892 pts with a kidney Tx between 2000-2007 were included who participated in the protocol biopsy program. Protocol biopsies were taken at 6 weeks, 3 and 6 months post-Tx. 862 biopsies for cause were taken in the 1st year and 262 thereafter. Subclinical and clinical acute rejections and clinical borderline rejections in protocol biopsies were treated. Pre-, peri- and post-transplant data were analysed in multivariable models at distinct time points (1.5, 3, 6, 12 and 24 months) after Tx.

Patient and graft survival was 80% at 5 years and 68% at 10 years. Death with functioning graft occurred in 99 pts; of the 116 pts with graft failure, 34 pts died while being on dialysis treatment. Infection was causative in 23%, cardiovascular disease in 14%, malignancy in 14%, and other specified causes in 6%. Deaths were less frequent in living-donor or kidney/pancreas transplantations and more frequent for extended donor criteria-transplantation.

Pre-transplant factors that were important at any time point after Tx included age, type 2 diabetes, peripheral and coronary artery disease. Hazard ratios of these factors were quite constant in the different multivariable models. Among the post-Tx factors, eGFR, urinary tract infection, urological complications, treated acute rejection episodes (in protocol biopsies and biopsies for cause), and cardiovascular events were significantly associated with death, with hazard ratios that were quite constant in the different models. Treatment of acute rejection was not specifically related to death due to infections. In addition, models at 1.5 and 3 months after Tx included HLA DR mismatch, cold ischemia time and delayed graft function, and severe infectious and non-infectious diseases. The concordance indices of the multivariable models ranged from 0.77 to 0.82. Models were validated by 200-bootstrapping, resulting in concordance indices of 0.75-0.81.

The identified factors allow stratification of patients according to their individual risk factors, as a pre-requisite for individualized and optimal post-transplant patient care.

CITATION INFORMATION: Scheffner I, Abeling T, Karch A, Mengel M, Broeker V, Koch A, Haller H, Schwarz A, Gwinner W. Death After Kidney Transplantation: Assessment of Pre- and Peri-Transplant Risk Factors and of Time-Varying Risk Factors from the Post-Transplant Course. Am J Transplant. 2017;17 (suppl 3).

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