Sasal J, Naimark D, Klassen J, Shea J, Bargman J M
Division of Nephrology, The University Health Network, Toronto, Ontario, Canada.
Perit Dial Int. 2001 Jul-Aug;21(4):405-10.
Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis.
To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant.
Peritoneal dialysis (PD) unit in a teaching hospital.
All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998.
There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group (p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease.
We conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.
早期肾移植失败需要重新开始透析已被证明是生存的不良预后因素。对于晚期移植失败后重新开始透析的患者的预后知之甚少。我们的临床印象是，晚期移植失败（>2个月）会使重新开始透析的患者发病和死亡风险增加。
确定肾移植失败的患者与从未接受过肾移植的透析患者的预后是否不同。
一家教学医院的腹膜透析（PD）科室。
确定了1989年至1996年期间多伦多医院腹膜透析项目中所有肾移植失败的患者（fTx）。将这42例fTx患者队列与一组随机选择的从未接受过移植的PD患者（非Tx）进行比较。选择该PD项目是因为有记录完善的患者档案材料。非Tx组在年龄和糖尿病存在情况方面进行了匹配。收集数据直至再次移植、透析方式或透析中心改变、死亡，或直至1998年6月。
两组开始PD时血清白蛋白、残余肾功能或平均血清甲状旁腺激素水平无差异。fTx队列的平均低密度脂蛋白水平显著更高。fTx患者移植前的透析时间导致了fTx患者总透析时间增加（平均15个月）。然而，移植后两组的PD持续时间相似（fTx为30.7个月，非Tx为31.6个月）。fTx组的预后明显比非Tx组差。fTx患者首次发生腹膜炎、随后的腹膜炎发作、更换导管或转为血液透析的时间要快得多。最显著的差异在于生存率。非Tx组有3例死亡，fTx组有12例死亡（p<0.01）。fTx组死亡时的平均年龄为47.5岁。死亡主要归因于革兰氏阴性菌腹膜炎和心血管疾病。
我们得出结论，开始透析的晚期肾移植失败患者并发症风险增加，死亡率明显高于非Tx患者。既往肾移植失败可被视为开始PD患者的不良预后因素；这些患者需要密切监测。尽管本研究仅限于PD患者，但相同原则可能适用于重新开始任何形式肾脏替代治疗的fTx患者。
