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Original Investigation |

Age-Related Kidney Transplant Outcomes:  Health Disparities Amplified in Adolescence

Kenneth A. Andreoni, MD1,2; Rachel Forbes, MD2; Regina M. Andreoni3; Gary Phillips, MAS4; Heather Stewart, MD5; Maria Ferris, MD, MPH, PhD5
[+] Author Affiliations
1Department of Surgery, University of Florida School of Medicine, Gainesville
2Department of Surgery, The Ohio State University, Columbus
3student at Oak Hall School, Gainesville, Florida
4Ohio State University Center for Biostatistics, The Ohio State University, Columbus
5Section of Pediatric Nephrology, Department of Medicine, University of North Carolina, Chapel Hill
JAMA Intern Med. 2013;173(16):1524-1532. doi:10.1001/jamainternmed.2013.8495.
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Importance  The transition from pediatric to adult health care is a vulnerable time for patients with chronic conditions. We need to better understand the factors affecting the health of kidney transplant recipients during this transition.

Objective  To determine the age at which renal transplant recipients are at greatest risk for graft loss.

Design, Setting, and Participants  We performed a retrospective analysis of 168 809 first kidney-only transplant events from October 1987 through October 2010, in recipients up to age 55 years as reported by the Organ Procurement Transplantation Network Standard Transplant Analysis and Research Database. Recipient age at transplant was the primary predictor studied. Confounder and effect modifier covariates were identified and studied using Cox proportional hazard models.

Exposure  Kidney-only transplant.

Main Outcomes and Measures  Patient and renal graft survival, along with death-censored and non–death-censored information.

Results  A total of 168 809 renal transplant events met the inclusion criteria. Recipients who received their first kidney transplant at age 14 to 16 years were at the highest risk of graft loss, with inferior outcomes starting at 1 and amplifying at 3, 5, and 10 years after transplant. Black adolescents were at disproportionately high risk of graft failure. The variables that had significant interaction with recipient age were donor type (deceased vs living) and insurance type (government vs private). Among 14-year-old recipients, the risk of death was 175% greater in the deceased donor–government insurance group vs the living donor–private insurance group (hazard ratio, 0.92 [95% CI, 0.90-0.94] vs 0.34 [95% CI, 0.33-0.36]), whereas patient survival rates in the living donor–government insurance and deceased donor–private insurance groups were nearly identical (hazard ratio, 0.61 [95% CI, 0.58-0.63] vs 0.54 [95% CI, 0.51-0.56]).

Conclusions and Relevance  Recipients aged 14 to 16 years have the greatest risk of kidney allograft failure. Black adolescents and those with government insurance are at even higher risk. Private insurance reduces risk of death across all ages. Comprehensive programs are needed for adolescents, especially for those at greater risk, to reduce graft loss during the transition from adolescence to adulthood.

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Figures

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Figure 1.
Graft Failure Relative Hazard According to Age at Transplant, Centered at 18 Years

A, Death censored; B, non–death censored. Graphs were produced using the following covariate pattern: race was white, sex was male, recipient’s and donor’s histories were negative for diabetes mellitus and hypertension, HLA mismatch level was 3, and donor age was 36 years.

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Figure 2.
Graft Survival According to Age at Transplant

Comparison of death-censored (A) and non–death-censored (B) graft survival across the 4 categories of recipients at 1, 3, 5, and 10 years after transplant. Death-censored analysis results favor graft outcomes in older recipients, who tend to die with a functioning graft, compared with non–death-censored outcomes, which favor younger recipients because of the larger number of deaths in the older group. Graphs were produced using the following covariate pattern: race was white, sex was male, recipient’s and donor’s histories were negative for diabetes mellitus and hypertension, HLA mismatch level was 3, and donor age was 36 years.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Relative Hazard of Death According to Age at Transplant, Centered at 18 Years

Graphs were produced using the following covariate pattern: race was white, sex was male, recipient’s and donor’s histories were negative for diabetes mellitus and hypertension, HLA mismatch level was 3, and donor age was 36 years.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
Graft Survival for a Recipient With a Deceased Donor and Government Insurance According to Age at Transplant

A, Death censored; B, non–death censored. Graphs were produced using the following covariate pattern: race was white, sex was male, recipient’s and donor’s histories were negative for diabetes mellitus and hypertension, HLA mismatch level was 3, and donor age was 36 years.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.
Graft Half-life (Median Survival) According to Age at Transplant

A, Death censored; B, non–death censored. Graphs were produced using the following covariate pattern: race was white, sex was male, recipient’s and donor’s histories were negative for diabetes mellitus and hypertension, HLA mismatch level was 3, and donor age was 36 years.

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Submit a Comment
Demand on the allograft as a cause of failure
Posted on September 27, 2013
Ashraf El-Meanawy
Medical College of Wisconsin
Conflict of Interest: None Declared
The high allograft failure rate in adolescent recipients is concerning. Other authors have attributed this problem to disruption of care with the switch from pediatric to adult Nephrologist. A confounding factor is this age group is nephron adequacy. Adequacy is the relation between demand and functional capacity. The demand can increase with metabolic demand. Adolescents are usually metabolically active. This increases the demand on the kidney and usually predispose to hype-filtration with consequent nephron damage and nephron dropout, which causes increase demand on the remaining nephrons. The metabolic demand is dictated by multiple factors including body surface area. It would be nice if the authors publish the biological parameters of donors and recipients and correlate the relations with allograt loss. Previously it was shown that transplanting kidney from a small person to a large one is associated with rapid decline of function and faster allograft loss. There is a need for a method to assess nephron number in the donated kidney and use that as tool to aid in organ allocation.
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