A Mayo Clinic 13-year investigation of the syndrome of rapid onset ESRD among renal transplant recipients: An analysis of the implications of renal allograft biopsy results.

INTRODUCTION

We first described the syndrome of rapid onset end stage renal disease (SORO-ESRD), acute yet irreversible renal failure, in 2010.

OBJECTIVE

The impact of SORO-ESRD renal allograft survival remains speculative and we plan to study this question.

METHODS

A retrospective analysis of individual adult patient-level serum creatinine trajectories of ESRD patients on maintenance hemodialysis for >90 days at Mayo Clinic, Rochester, 2001-2013.

RESULTS

Of 1461 ESRD patients, 149 (10%) patients including 13 renal transplant recipients (RTRs) satisfied the diagnosis of SORO-ESRD - 4 males, 9 females, 12 Caucasians/one other, age 45 (18-83) years. Serum creatinine was 1.4 (0.8-1.7) mg/dL in the last year before hemodialysis initiation. Initial hemodialysis access was a dialysis catheter in all 13 patients. AKI precipitating SORO-ESRD followed acute rejection (4), postoperative (2), tubulo-interstitial nephritis (2), unknown (2), infection/sepsis (1), contrast nephropathy (1), BKV nephropathy (1), and cardio-renal syndrome (1). Renal allograft survival was 1469 (277-4939) days (4 years). Renal allograft biopsies were available in 9/14 (69%) RTRs - Four showed acute rejection, two of which followed interruption of immunosuppression, three revealed acute tubular necrosis and four others also showed chronic transplant glomerulopathy. Time on hemodialysis was 856 (129-1630) days (2.4 years). 5/13 RTRs with SORO-ESRD (38%) died - 3 (60%) following cardiac arrest, 2 (40%) after stopping hemodialysis. 4/13 (31%) were re-transplanted in the period of this study.

CONCLUSION

SORO-ESRD contributed significantly to late renal allograft loss and return to hemodialysis with 100% initial dialysis catheter rate. Potentially preventable causes of AKI leading to SORO-ESRD were identified. The application of experience gained from such studies would help reduce late renal allograft loss and the need for re-transplantation. This would further help reduce the yawning gap between need and availability of donor kidney organs both here in the United States and around the world. Larger studies are warranted.