RESUMEN
Existing approaches for infection risk stratification in kidney transplant recipients are suboptimal. Here, we aimed to develop and validate a weighted score integrating non-pathogen-specific immune parameters and clinical variables to predict the occurrence of post-transplant infectious complications. To this end, we retrospectively analyzed a single-center derivation cohort of 410 patients undergoing kidney transplantation in 2008-2013 in Madrid. Peripheral blood lymphocyte subpopulations, serum immunoglobulin and complement levels were measured at one-month post-transplant. The primary and secondary outcomes were overall and bacterial infection through month six. A point score was derived from a logistic regression model and prospectively applied on a validation cohort of 522 patients undergoing kidney transplantation at 16 centers throughout Spain in 2014-2015. The SIMPLICITY score consisted of the following variables measured at month one after transplantation: C3 level, CD4+ T-cell count, CD8+ T-cell count, IgG level, glomerular filtration rate, recipient age, and infection within the first month. The discrimination capacity in the derivation and validation cohorts was good for overall (areas under the receiver operating curve of 0.774 and 0.730) and bacterial infection (0.767 and 0.734, respectively). The cumulative incidence of overall infection significantly increased across risk categories in the derivation (low-risk 13.7%; intermediate-risk, 35.9%; high-risk 77.6%) and validation datasets (10.2%, 28.9% and 50.4%, respectively). Thus, the SIMPLICITY score, based on easily available immune parameters, allows for stratification of kidney transplant recipients at month one according to their expected risk of subsequent infection.
Asunto(s)
Trasplante de Riñón , Humanos , Trasplante de Riñón/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , España/epidemiología , Receptores de TrasplantesRESUMEN
BACKGROUND AND OBJECTIVE: The number of patients who start dialysis due to graft failure increases every day. The best dialysis modality for this type of patient is not well defined and most patients are referred to HD. The objective of our study is to evaluate the impact of the dialysis modality on morbidity and mortality in transplant patients who start dialysis after graft failure. MATERIAL AND METHODS: A multicentre retrospective observation and cohort study was performed to compare the evolution of patients who started dialysis after graft failure from January 2000 to December 2013. One group started on PD and the other on HD. The patients were followed until the change of dialysis technique, retransplantation or death. Anthropometric data, comorbidity, estimated glomerular filtration rate (eGFR) at start of dialysis, the presence of an optimal access for dialysis, the appearance of graft intolerance and retransplantation were analyzed. We studied the causes for the first 10 hospital admissions after starting dialysis. For the statistical analysis, the presence of competitive events that hindered the observation of the event of interest, death or hospital admission was analyzed. RESULTS: 175 patients were included, 86 in DP and 89 in HD. The patients who started PD were younger, had less comorbidity and started dialysis with lower eGFR than those on HD. The mean follow-up was 34 ± 33 months, with a median of 24 months (IQR 7-50 months), Patients on HD had longer follow-up than patients on PD (35 vs. 18 months, p = < 0.001). The mortality risk factors were age sHR 1.06 (95% CI: 1.03-1.106, p = 0.000), non-optimal use of access for dialysis sHR 3.00 (95% CI: 1.507-5.982, p = 0.028) and the dialysis modality sHR (PD/HD) 0.36 (95% CI: 0.148-0.890, p = 0.028). Patients on PD had a lower risk of hospital admission sHR [DP/HD] 0.52 (95% CI: 0.369-0.743, p = < 0.001) and less probability of developing graft intolerance HR 0.307 (95% CI 0.142-0.758, p = 0.009). CONCLUSIONS: With the limitations of a retrospective and non-randomized study, it is the first time nationwide that PD shows in terms of survival to be better than HD during the first year and a half after the kidney graft failure. The presence of a non-optimal access for dialysis was an independent and modifiable risk factor for mortality. Early referral of patients to advanced chronic kidney disease units is essential for the patient to choose the technique that best suits their circumstances and to prepare an optimal access for the start of dialysis.
RESUMEN
BACKGROUND AND OBJECTIVE: The number of patients who start dialysis due to graft failure increases every day. The best dialysis modality for this type of patient is not well defined and most patients are referred to HD. The objective of our study is to evaluate the impact of the dialysis modality on morbidity and mortality in transplant patients who start dialysis after graft failure. MATERIAL AND METHODS: A multicentre retrospective observation and cohort study was performed to compare the evolution of patients who started dialysis after graft failure from January 2000 to December 2013. One group started on PD and the other on HD. The patients were followed until the change of dialysis technique, retransplantation or death. Anthropometric data, comorbidity, estimated glomerular filtration rate (eGFR) at start of dialysis, the presence of an optimal access for dialysis, the appearance of graft intolerance and retransplantation were analysed. We studied the causes for the first 10 hospital admissions after starting dialysis. For the statistical analysis, the presence of competitive events that hindered the observation of the event of interest, death or hospital admission was analysed. RESULTS: 175 patients were included, 86 in DP and 89 in HD. The patients who started PD were younger, had less comorbidity and started dialysis with lower eGFR than those on HD. The mean follow-up was 34 ± 33 months, with a median of 24 months (IQR 7 - 50 months), Patients on HD had longer follow-up than patients on PD (35 vs. 18 months, p = < 0.001). The mortality risk factors were age sHR 1.06 (95% CI: 1.033 - 1.106, p = 0.000), non-optimal use of access for dialysis sHR 3.00 (95% CI: 1.507 - 5.982, p = 0.028) and the dialysis modality sHR (PD / HD) 0.36 (95% CI: 0.148 - 0.890, p = 0.028). Patients on PD had a lower risk of hospital admission sHR [DP / HD] 0.52 (95% CI: 0.369-0.743, p = < 0.001) and less probability of developing graft intolerance HR 0.307 (95% CI 0.142-0.758, p = 0.009). CONCLUSIONS: With the limitations of a retrospective and non-randomized study, it is the first time nationwide that PD shows in terms of survival to be better than HD during the first year and a half after the kidney graft failure. The presence of a non-optimal access for dialysis was an independent and modifiable risk factor for mortality. Early referral of patients to advanced chronic kidney disease units is essential for the patient to choose the technique that best suits their circumstances and to prepare an optimal access for the start of dialysis.
Asunto(s)
Soluciones para Diálisis/efectos adversos , Eritema/inducido químicamente , Exantema/inducido químicamente , Icodextrina/efectos adversos , Diálisis Peritoneal , Adulto , Anciano , Femenino , Dermatosis de la Mano/inducido químicamente , Humanos , Fallo Renal Crónico/terapia , Masculino , Prurito/inducido químicamenteRESUMEN
ANTECEDENTES Y OBJETIVO: El número de personas que inician diálisis por el fracaso del injerto aumenta cada día. La modalidad de diálisis mejor para este tipo de pacientes no está bien definida y la mayoría de ellos son derivados a hemodiálisis (HD). El objetivo de nuestro estudio es evaluar el impacto de la modalidad de diálisis sobre la morbilidad y la mortalidad en individuos trasplantados que inician este procedimiento tras el fracaso del injerto. MATERIAL Y MÉTODOS: Estudio multicéntrico retrospectivo observacional y de cohortes que compara la evolución de los pacientes que inician diálisis tras el fracaso del injerto, desde enero del año 2000 a diciembre del 2013. Un grupo lo hace en diálisis peritoneal (DP) y otro en HD. Se realizó un seguimiento a los pacientes hasta el cambio de técnica de diálisis, retrasplante o fallecimiento. Se analizaron datos antropométicos, comorbilidad, el filtrado glomerular (FG) con el que iniciaban la diálisis, la presencia de un acceso óptimo para esta, la presencia de intolerancia al injerto y el retrasplante. Estudiamos el motivo de los 10 primeros ingresos hospitalarios tras el inicio de la diálisis. Para el análisis estadístico, se tuvo en cuenta la presencia de eventos competitivos que dificultaran la aparición del evento de interés, muerte o ingreso hospitalario. RESULTADOS: Se incluyeron 175 pacientes. En DP 86 y 89 en HD. Los individuos que iniciaron DP eran más jóvenes, tenían menor comorbilidad y lo hacían con FG más bajos que los de HD. El seguimiento medio fue de 34 ± 33 meses, con una mediana de 24 (IQR siete a 50 meses), siendo mayor en los pacientes en HD que en los de DP (35 vs. 18 meses, p = < 0,001). Los factores de riesgo que influyeron en la mortalidad fueron la edad (coeficiente del sub Hazard Ratio [sHR] 1,06 (IC 95%: 1,033 a 1,106, p = 0,000), el uso no óptimo del acceso (sHR 3,00 (IC 95%: 1,507 a 5,982, p = 0,028) y el tipo de diálisis, la DP sHR[DP/HD] 0,36 (IC 95%: 0,148 a 0,890, p = 0,028). Los pacientes en DP tenían menos riesgo de un ingreso hospitalario sHR[DP/HD] 0,52 (IC 95%: 0,369 a 0,743, p = < 0,001) y menos probabilidad de desarrollar una intolerancia al injerto HR 0,307 (IC 95% 0,142 a 0,758, p = 0,009). CONCLUSIONES: Con las limitaciones de un estudio retrospectivo y no randomizado, es la primera vez a nivel nacional que se demuestra que la DP en términos de supervivencia es mejor que la HD cuando fracasa el injerto durante el primer año y medio en diálisis. La presencia de un acceso no óptimo para este procedimiento es un factor de riesgo de mortalidad independiente y modificable. La remisión precoz de los pacientes a las unidades de enfermedad renal crónica avanzada (ERCA) es fundamental para que estos elijan la técnica que más se adapte a sus circunstancias y preparar un acceso óptimo para el inicio de diálisis
BACKGROUND AND OBJECTIVE: The number of patients who start dialysis due to graft failure increases every day. The best dialysis modality for this type of patient is not well defined and most patients are referred to HD. The objective of our study is to evaluate the impact of the dialysis modality on morbidity and mortality in transplant patients who start dialysis after graft failure. MATERIAL AND METHODS: A multicentre retrospective observation and cohort study was performed to compare the evolution of patients who started dialysis after graft failure from January 2000 to December 2013. One group started on PD and the other on HD. The patients were followed until the change of dialysis technique, retransplantation or death. Anthropometric data, comorbidity, estimated glomerular filtration rate (eGFR) at start of dialysis, the presence of an optimal access for dialysis, the appearance of graft intolerance and retransplantation were analysed. We studied the causes for the first 10 hospital admissions after starting dialysis. For the statistical analysis, the presence of competitive events that hindered the observation of the event of interest, death or hospital admission was analysed. RESULTS: 175 patients were included, 86 in DP and 89 in HD. The patients who started PD were younger, had less comorbidity and started dialysis with lower eGFR than those on HD. The mean follow-up was 34 ± 33 months, with a median of 24 months (IQR 7 - 50 months), Patients on HD had longer follow-up than patients on PD (35 vs. 18 months, p = < 0.001). The mortality risk factors were age sHR 1.06 (95% CI: 1.033 - 1.106, p = 0.000), non-optimal use of access for dialysis sHR 3.00 (95% CI: 1.507 - 5.982, p = 0.028) and the dialysis modality sHR (PD / HD) 0.36 (95% CI: 0.148 - 0.890, p = 0.028). Patients on PD had a lower risk of hospital admission sHR [DP / HD] 0.52 (95% CI: 0.369-0.743, p = < 0.001) and less probability of developing graft intolerance HR 0.307 (95% CI 0.142-0.758, p = 0.009). CONCLUSIONS: With the limitations of a retrospective and non-randomized study, it is the first time nationwide that PD shows in terms of survival to be better than HD during the first year and a half after the kidney graft failure. The presence of a non-optimal access for dialysis was an independent and modifiable risk factor for mortality. Early referral of patients to advanced chronic kidney disease units is essential for the patient to choose the technique that best suits their circumstances and to prepare an optimal access for the start of dialysis
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Diálisis Renal/mortalidad , Trasplante de Riñón/mortalidad , Rechazo de Injerto/mortalidad , Estudios Retrospectivos , Diálisis Renal/métodos , Insuficiencia del Tratamiento , Comorbilidad , Factores de Riesgo , Estimación de Kaplan-Meier , Factores de Edad , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/cirugíaRESUMEN
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