1 Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL. 2 Miami Transplant Institute, Department of Medicine, University of Miami Miller School of Medicine; Miami, FL. 3 Address correspondence to: Jeffrey J. Gaynor, Ph.D., Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, PO Box 012440 (R-440), Miami, FL 33101.
Transplantation. 2014 May 15;97(9):925-33. doi: 10.1097/01.TP.0000438199.76531.4a.
In adult kidney transplantation, there is no clear consensus on the incidence of graft failure-due-to noncompliance (GFNC), with some reporting it as relatively uncommon and others as a major cause of late graft failure. We suspected that GFNC was a major cause of late graft loss at our center but did not know the extent of this problem.
In our prospectively followed cohort of 628 adult, primary kidney-alone transplant recipients with long-term follow-up, GFNC and other graft loss causes were determined from our ongoing clinical evaluations. Using competing risks methodology, we determined the overall percentage of patients developing GFNC and the significant prognostic factors for its hazard rate and cumulative incidence (via Cox regression).
Cumulative incidence estimates (± standard error) of GFNC (n=29), GF-with-compliance (n=46), receiving a never-functioning graft (n=7), and death-with-a-functioning-graft (n=53) at 101 months after transplant (last-observed-graft loss) were as follows: 9.8%± 2.4%, 10.9%± 1.7%, 1.1%± 0.4%, and 13.0%± 1.9%, respectively. Only three patients experienced GFNC during the first 24 months; GFNC represented 48.1% (26/54) of death-censored GFs beyond 24 months. Two baseline variables were jointly associated with a significantly higher GFNC hazard and cumulative incidence: younger recipient age (P<0.000001 each) and non-white recipient (P=0.004 and P=0.02). Estimated percentages of ever developing GFNC were 28.4%± 6.5% among 79 non-whites younger than 35 years versus 0.0% (0/144) among whites 50 years or older. Among 302 recipients younger than 50 years, 18.1%± 4.1% developed GFNC, representing 67.6% (25/37) of its death-censored graft failures observed beyond 24 months after transplant.
GFNC is a major cause of late GF at our center, with younger and non-white recipients at a significantly greater GFNC risk. Interventional approaches to eliminate GFNC could dramatically improve long-term kidney graft survival.
在成人肾脏移植中，由于不遵医嘱导致移植物失功（GFNC）的发生率尚无明确共识，一些研究认为其相对少见，而另一些研究则认为其是晚期移植物失功的主要原因。我们怀疑 GFNC 是我们中心晚期移植物丢失的主要原因，但不知道这个问题的严重程度。
在我们前瞻性随访的 628 例成年、单纯肾脏移植受者的长期随访队列中，根据我们正在进行的临床评估，确定 GFNC 及其他移植物丢失原因。采用竞争风险方法，我们确定了发生 GFNC 的患者总体百分比，以及其危险率和累积发生率的显著预后因素（通过 Cox 回归）。
移植后 101 个月（最后一次观察到移植物丢失），GFNC（n=29）、GF 伴遵嘱（n=46）、接受无功能移植物（n=7）和带功能移植物死亡（n=53）的累积发生率（±标准误差）分别为 9.8%±2.4%、10.9%±1.7%、1.1%±0.4%和 13.0%±1.9%。仅有 3 例患者在移植后 24 个月内发生 GFNC；GFNC 占移植后 24 个月以上死亡校正移植物的 48.1%（26/54）。仅 2 个基线变量与显著更高的 GFNC 危险和累积发生率相关：受者年龄较小（均 P<0.000001）和非白人受者（P=0.004 和 P=0.02）。在 79 名年龄小于 35 岁的非白人患者中，预计会发生 GFNC 的百分比为 28.4%±6.5%，而在 50 岁或以上的白人患者中，这一比例为 0.0%（0/144）。在 302 名年龄小于 50 岁的受者中，18.1%±4.1%发生了 GFNC，占移植后 24 个月以上死亡校正移植物失功的 67.6%（25/37）。
在我们中心，GFNC 是晚期 GF 的主要原因，年轻和非白人受者发生 GFNC 的风险显著增加。消除 GFNC 的干预措施可能会显著改善长期肾脏移植物的存活率。
