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American Journal of Kidney Diseases

Impact of Diabetes Mellitus on the Association of Vascular Disease Before Transplantation With Long-term Transplant and Patient Outcomes After Kidney Transplantation: A Population Cohort Study

  • Wai H. Lim
    Correspondence
    Address for Correspondence: Wai H. Lim, PhD, Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia 6009.
    Affiliations
    Department of Renal Medicine, Sir Charles Gairdner Hospital, Western Australia, Australia

    School of Medicine and Pharmacology, University of Western Australia, Perth, Australia

    Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
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  • David W. Johnson
    Affiliations
    Princess Alexandra Hospital, Metro South and Ipswich Nephrology and Transplant Services, Queensland, Australia

    University of Queensland, Queensland, Australia

    Translational Research Institute, Brisbane, Australia
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  • Carmel M. Hawley
    Affiliations
    Princess Alexandra Hospital, Metro South and Ipswich Nephrology and Transplant Services, Queensland, Australia

    University of Queensland, Queensland, Australia

    Translational Research Institute, Brisbane, Australia
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  • Elaine Pascoe
    Affiliations
    University of Queensland, Queensland, Australia
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  • Germaine Wong
    Affiliations
    Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia

    Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia

    Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia

    Sydney School of Public Health, University of Sydney, Sydney, Australia
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Published:November 27, 2017DOI:https://doi.org/10.1053/j.ajkd.2017.08.018

      Background

      Advances in kidney transplantation have led to considerable improvements in short-term transplant and patient outcomes, but there are few data regarding long-term transplant outcomes in patients with vascular comorbid conditions. This study examined the association of vascular disease before transplantation with transplant and patient survival after transplantation and evaluated whether this association was modified by diabetes.

      Study Design

      All deceased donor kidney transplant recipients recorded in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) for 1990 to 2012.

      Predictor

      Vascular disease burden.

      Outcomes

      All-cause mortality and overall transplant loss. Potential interactions between diabetes and vascular disease for mortality and transplant loss were assessed using 2-way interaction terms.

      Results

      Of 7,128 recipients with 58,120 patient-years of follow-up, 854 (12.0%) and 263 (3.7%) had vascular diseases at 1 and 2 or more sites, respectively. Overall survival for recipients without vascular disease 15 years after transplantation was 65% compared with 35% and 22% among recipients with vascular disease at 1 and 2 or more sites, respectively (P < 0.001). Compared with recipients without vascular disease, adjusted HRs for mortality and transplant loss were 1.75 (95% CI, 1.39-2.20; P < 0.001) and 1.61 (95% CI, 1.30-1.99; P < 0.001), respectively, for recipients with 2 or more vascular diseases. Among recipients without diabetes but with 2 or more vascular diseases, adjusted HRs for mortality and transplant loss were 2.10 (95% CI, 1.56-2.82; P < 0.001) and 1.84 (95% CI, 1.39-2.42; P < 0.001), respectively, compared with those without vascular disease. Similar associations were not observed for recipients with diabetes mellitus (P for interaction < 0.001).

      Limitations

      Selection bias and unmeasured residual confounders, such as the severity/extent of comorbid conditions likely to be present.

      Conclusions

      The impact of vascular disease on long-term outcomes was modified by the presence of diabetes, whereby excess risks for death and transplant loss are more apparent in recipients without diabetes.

      Index Words

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      References

        • Snyder J.
        • Kasiske B.
        • Maclean R.
        Peripheral arterial disease and renal transplantation.
        J Am Soc Nephrol. 2006; 17: 2056-2068
        • Ott U.
        • Busch M.
        • Steiner T.
        • Wolf G.
        Presence of cardiovascular disease in patients on a waiting list for renal transplantation and in patients after kidney transplantation in a single center.
        Transplant Proc. 2010; 42: 3450-3454
        • Morales J.M.
        • Marcen R.
        • del Castillo D.
        • et al.
        Risk factors for graft loss and mortality after renal transplantation according to recipient age: a prospective multicentre study.
        Nephrol Dial Transplant. 2012; 27: iv39-iv46
        • Ojo A.O.
        • Hanson J.A.
        • Wolfe R.A.
        • Leichtman A.B.
        • Agodoa L.Y.
        • Port F.K.
        Long-term survival in renal transplant recipients with graft function.
        Kidney Int. 2000; 57: 307-313
        • Howard R.J.
        • Patton P.R.
        • Reed A.I.
        • et al.
        The changing causes of graft loss and death after kidney transplantation.
        Transplantation. 2002; 73: 1923-1928
        • Pilmore H.
        • Dent H.
        • Chang S.
        • McDonald S.
        • Chadban S.
        Reduction in cardiovascular death after kidney transplantation.
        Transplantation. 2010; 89: 851-857
        • Knoll G.
        • Cockfield S.
        • Blydt-Hansen T.
        • et al.
        Canadian Society of Transplantation: consensus guidelines on eligibility for kidney transplantation.
        CMAJ. 2005; 173: S1-S25
        • Dudley C.
        • Harden P.
        Renal Association clinical practice guideline on the assessment of the potential kidney transplant recipient.
        Nephron Clin Pract. 2011; 118: c209-c224
        • Prentice R.L.
        • Kalbfleisch J.D.
        • Peterson Jr., A.V.
        • Flournoy N.
        • Farewell V.T.
        • Breslow N.E.
        The analysis of failure times in the presence of competing risks.
        Biometrics. 1978; 34: 541-554
        • Fine J.
        • Gray R.
        A proportional hazards model for the subdistribution of a competing risk.
        J Am Stat Assoc. 1999; 94: 496-509
        • Rajagopalan S.
        • Dellegrottaglie S.
        • Furniss A.
        • et al.
        Peripheral arterial disease in patients with end-stage renal disease: observations from the Dialysis Outcomes and Practice Patterns Study (DOPPS).
        Circulation. 2006; 114: 1914-1922
        • Sarnak M.
        • Levey A.
        • Schoolwerth A.
        • et al.
        Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.
        Circulation. 2003; 108: 2154-2169
        • Mailloux L.
        • Napolitano B.
        • Bellucci A.
        • Mossey R.
        • Vernace M.
        • Wilkes B.
        The impact of co-morbid risk factors at the start of dialysis upon the survival of ESRD patients.
        ASAIO J. 1996; 42: 164-169
        • Tonelli M.
        • Wiebe N.
        • Culleton B.
        • et al.
        Chronic kidney disease and mortality risk: a systematic review.
        J Am Soc Nephrol. 2006; 17: 2034-2047
        • Dalrymple L.S.
        • Katz R.
        • Kestenbaum B.
        • et al.
        Chronic kidney disease and the risk of end-stage renal disease versus death.
        J Gen Intern Med. 2011; 26: 379-385
        • US Renal Data System
        USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.
        National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2007
        • Kasiske B.L.
        • Maclean J.R.
        • Snyder J.J.
        Acute myocardial infarction and kidney transplantation.
        J Am Soc Nephrol. 2006; 17: 900-907
        • Gill J.S.
        Cardiovascular disease in transplant recipients: current and future treatment strategies.
        Clin J Am Soc Nephrol. 2008; 3: S29-S37
        • Wu C.
        • Evans I.
        • Joseph R.
        • et al.
        Comorbid conditions in kidney transplantation: association with graft and patient survival.
        J Am Soc Nephrol. 2005; 16: 3437-3444
        • Jassal S.V.
        • Schaubel D.E.
        • Fenton S.S.
        Baseline comorbidity in kidney transplant recipients: a comparison of comorbidity indices.
        Am J Kidney Dis. 2005; 46: 136-142
        • Laging M.
        • Kal-van Gestel J.A.
        • van de Wetering J.
        • et al.
        A high comorbidity score should not be a contraindication for kidney transplantation.
        Transplantation. 2016; 100: 400-406