Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria.
Department of Nephrology, Medical University of Vienna, Vienna, Austria.
Nephrol Dial Transplant. 2019 Apr 1;34(4):555-560. doi: 10.1093/ndt/gfy099.
Pre-emptive kidney transplantation is the recommended strategy for patients with end-stage renal failure in all guidelines [Kidney Disease: Improving Global Outcomes (KDIGO), The Australian and New Zealand Dialysis and Transplantation Registry (ANZDATA), European Renal Best Practice Guideline (ERBP), British Transplant Society (BTS)]. This recommendation is intuitive and based on few older studies with considerable limitations. In addition, there is conflicting evidence as to whether the duration of dialysis vintage impacts on graft and patient survival after transplantation. The objective of this structured review was to critically review the published evidence on dialysis vintage and outcomes by including the most recent papers on that topic. We searched Medline using keywords for kidney transplantation, pre-emptive, dialysis vintage and relevant outcomes, and found 14 eligible cohort studies. The best evidence was found for pre-emptive transplantation, which was found to be associated with a lower risk of actual graft loss (including death as event) compared with non-pre-emptive transplantation. When only patients were considered that have been registered pre-emptively but then received or did not receive a pre-emptive transplant, the association with functional graft survival (excluding death as event) was only marginal. Dialysis vintage had a graded association with patient survival in most of the studies, but an unclear estimate with functional graft survival. Older studies also found an association of dialysis vintage with death-censored graft survival, but this association is likely confounded by selection and the competing risk of death and was no longer observed in recent eras, i.e. in transplants performed in the last decade. In summary, the recommendation for pre-emptive kidney transplantation for optimal patient and graft survival remains valid even in recent periods but the association of dialysis vintage after dialysis initiation with death-censored graft survival is less clear. The association of dialysis vintage with mortality after transplantation depends on the median duration of dialysis of the wait-listed population as well as acceptance rates for transplantation, and may thus be country specific. Nevertheless, it is reasonable to advocate pre-emptive kidney transplantation in all age groups. What remains unsolved is the selection issues since the reasons for longer waiting time on dialysis are difficult to capture in retrospective observational studies, and lead time as well as immortal time bias may have confounded the mortality data.
预先进行肾脏移植是所有指南[肾脏病：改善全球结局（KDIGO）、澳大利亚和新西兰透析和移植登记处（ANZDATA）、欧洲肾脏最佳实践指南（ERBP）、英国移植学会（BTS）]推荐的终末期肾衰竭患者的策略。这一推荐是直观的，并且基于少数具有相当大局限性的较旧研究。此外，关于透析龄是否会影响移植后移植物和患者的存活率，还存在相互矛盾的证据。本系统综述的目的是批判性地回顾关于透析龄和结局的已发表证据，包括该主题的最新文献。我们使用肾脏移植、预先、透析龄和相关结局的关键词在 Medline 上进行了搜索，并找到了 14 项合格的队列研究。预先进行肾脏移植的最佳证据表明，与非预先进行肾脏移植相比，它与实际移植物丢失（包括作为事件的死亡）的风险较低相关。当仅考虑那些已预先登记但随后接受或未接受预先移植的患者时，与功能移植物存活率（不包括作为事件的死亡）的关联仅具有边缘意义。在大多数研究中，透析龄与患者存活率呈分级关联，但在功能移植物存活率方面的估计不明确。较旧的研究还发现透析龄与死亡相关的移植物存活率之间存在关联，但这种关联可能受到选择和死亡的竞争风险的混淆，并且在最近的时代不再观察到，即在上个十年中进行的移植中。总之，即使在最近的时期，为了优化患者和移植物的存活率而推荐预先进行肾脏移植仍然是有效的，但透析开始后与死亡相关的移植物存活率之间的透析龄关联不太清楚。移植后与死亡率相关的透析龄取决于等待移植人群的透析中位数以及接受移植的比例，并且可能因国家而异。然而，在所有年龄段都提倡预先进行肾脏移植是合理的。仍然没有解决的是选择问题，因为在回顾性观察研究中很难捕捉到导致透析等待时间延长的原因，并且领先时间和不朽时间偏差可能混淆了死亡率数据。
