Advertisement
American Journal of Kidney Diseases

Mortality and Allograft Loss Trends Among US Pediatric Kidney Transplant Recipients With and Without Focal Segmental Glomerulosclerosis

  • Chia-shi Wang
    Correspondence
    Address for Correspondence: Chia-shi Wang, MD, MSc, Division of Pediatric Nephrology, 2015 Uppergate Dr NE, Atlanta, GA 30322-1015.
    Affiliations
    Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA

    Children’s Healthcare of Atlanta, Atlanta, GA
    Search for articles by this author
  • Jennifer Gander
    Affiliations
    Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
    Search for articles by this author
  • Rachel E. Patzer
    Affiliations
    Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA

    Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA
    Search for articles by this author
  • Larry A. Greenbaum
    Affiliations
    Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA

    Children’s Healthcare of Atlanta, Atlanta, GA
    Search for articles by this author
Published:December 22, 2017DOI:https://doi.org/10.1053/j.ajkd.2017.09.025

      Background

      Pediatric patients with focal segmental glomerulosclerosis (FSGS) have high rates of disease recurrence and allograft failure after kidney transplantation, but there are few data for long-term survival posttransplantation.

      Study Design

      Retrospective cohort study.

      Setting & Participants

      12,303 pediatric patients (aged <18 years), including 1,408 (11%) patients with FSGS, who received a first kidney transplant in 1990 through 2009 and were followed up through June 2015 were identified from the US Renal Data System database.

      Predictors

      Primary cause of end-stage renal disease, FSGS or other.

      Outcomes

      All-cause patient mortality and allograft loss.

      Results

      All-cause mortality significantly improved for patients with FSGS who underwent transplantation in the 2000s versus the 1990s (6.72 vs 12.24 deaths/1,000 patient-years; HR, 0.55; 95% CI, 0.39-0.78; P < 0.001). Reductions in allograft loss were less dramatic (75.91 vs 89.05 events/1,000 patient-years; HR, 0.85; 95% CI, 0.74-0.98; P = 0.02). After adjusting for baseline characteristics at the time of transplantation, patients with FSGS had similar rates of death compared with patients without FSGS (HRs of 0.81 [P = 0.6] and 1.06 [P = 0.2] among those who underwent transplantation in the 2000s and 1990s, respectively) despite higher rates of allograft loss (HRs of 1.17 [P= 0.03] and 1.27 [P < 0.001], respectively). Among patients who underwent transplantation in the 2000s, further adjustment for allograft failure as a time-varying covariate demonstrated a lower rate of death among patients with FSGS compared with those without FSGS (HR, 0.70; P= 0.02).

      Limitations

      Lack of information about certain risk factors for mortality, including duration of chronic kidney disease; missing data; and potential primary disease misclassification.

      Conclusions

      Survival of pediatric kidney transplant recipients with FSGS improved between the 1990s and 2000s and was similar to that of recipients without FSGS. Interestingly, adjustment for allograft failure showed greater survival for pediatric patients with FSGS who underwent transplantation in the 2000s as compared with others, suggesting that effective interventions to decrease allograft loss due to disease recurrence may improve patient survival.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kitiyakara C.
        • Eggers P.
        • Kopp J.B.
        Twenty-one-year trend in ESRD due to focal segmental glomerulosclerosis in the United States.
        Am J Kidney Dis. 2004; 44: 815-825
        • Smith J.M.
        • Martz K.
        • Blydt-Hansen T.D.
        Pediatric kidney transplant practice patterns and outcome benchmarks, 1987-2010: a report of the North American Pediatric Renal Trials and Collaborative Studies.
        Pediatr Transplant. 2013; 17: 149-157
        • Tejani A.
        • Stablein D.H.
        Recurrence of focal segmental glomerulosclerosis posttransplantation: a special report of the North American Pediatric Renal Transplant Cooperative Study.
        J Am Soc Nephrol. 1992; 2: S258-S263
        • Guan I.
        • Singer P.
        • Frank R.
        • Chorny N.
        • Infante L.
        • Sethna C.B.
        Role of race in kidney transplant outcomes in children with focal segmental glomerulosclerosis.
        Pediatr Transplant. 2016; 20: 790-797
        • Dall'Amico R.
        • Ghiggeri G.
        • Carraro M.
        • et al.
        Prediction and treatment of recurrent focal segmental glomerulosclerosis after renal transplantation in children.
        Am J Kidney Dis. 1999; 34: 1048-1055
        • Cleper R.
        • Krause I.
        • Bar Nathan N.
        • et al.
        Focal segmental glomerulosclerosis in pediatric kidney transplantation: 30 years' experience.
        Clin Transplant. 2016; 30: 1324-1331
        • Carl S.
        • Wiesel M.
        • Wuhl E.
        • Mehls O.
        • Schaefer F.
        • Staehler G.
        Outcome of children and adolescents with recurrent nephrotic syndrome and focal segmental glomerulosclerosis after renal transplantation.
        Transplant Proc. 1997; 29: 2795-2796
        • Artero M.
        • Biava C.
        • Amend W.
        • Tomlanovich S.
        • Vincenti F.
        Recurrent focal glomerulosclerosis: natural history and response to therapy.
        Am J Med. 1992; 92: 375-383
        • Francis A.
        • Trnka P.
        • McTaggart S.J.
        Long-term outcome of kidney transplantation in recipients with focal segmental glomerulosclerosis.
        Clin J Am Soc Nephrol. 2016; 11: 2041-2046
        • Briganti E.M.
        • Russ G.R.
        • McNeil J.J.
        • Atkins R.C.
        • Chadban S.J.
        Risk of renal allograft loss from recurrent glomerulonephritis.
        N Engl J Med. 2002; 347: 103-109
        • Baum M.A.
        • Stablein D.M.
        • Panzarino V.M.
        • Tejani A.
        • Harmon W.E.
        • Alexander S.R.
        Loss of living donor renal allograft survival advantage in children with focal segmental glomerulosclerosis.
        Kidney Int. 2001; 59: 328-333
        • Foster B.J.
        • Dahhou M.
        • Zhang X.
        • Platt R.W.
        • Hanley J.A.
        Change in mortality risk over time in young kidney transplant recipients.
        Am J Transplant. 2011; 11: 2432-2442
        • Kaplan B.
        • Meier-Kriesche H.U.
        Death after graft loss: an important late study endpoint in kidney transplantation.
        Am J Transplant. 2002; 2: 970-974
        • O'Shaughnessy M.M.
        • Liu S.
        • Montez-Rath M.E.
        • Lenihan C.R.
        • Lafayette R.A.
        • Winkelmayer W.C.
        Kidney transplantation outcomes across GN subtypes in the United States.
        J Am Soc Nephrol. 2017; 28: 632-644
        • Saran R.
        • Li Y.
        • Robinson B.
        • et al.
        US Renal Data System 2015 Annual Data Report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2016; 67: S1-S434
        • Layton J.B.
        • Hogan S.L.
        • Jennette C.E.
        • et al.
        Discrepancy between Medical Evidence Form 2728 and renal biopsy for glomerular diseases.
        Clin J Am Soc Nephrol. 2010; 5: 2046-2052
        • Pardon A.
        • Audard V.
        • Caillard S.
        • et al.
        Risk factors and outcome of focal and segmental glomerulosclerosis recurrence in adult renal transplant recipients.
        Nephrol Dial Transplant. 2006; 21: 1053-1059
        • Baum M.A.
        • Ho M.
        • Stablein D.
        • Alexander S.R.
        North American Pediatric Renal Transplant Cooperative Study. Outcome of renal transplantation in adolescents with focal segmental glomerulosclerosis.
        Pediatr Transplant. 2002; 6: 488-492