Perit Dial Int
29(Supplement_2):
117-122
2009
© 2009 International Society for Peritoneal Dialysis
Part 3: Clinical Experiences |
EFFECT OF PRE-TRANSPLANT DIALYSIS MODALITY ON KIDNEY TRANSPLANTATION OUTCOME
Yasar Caliskan,
Halil Yazici,
Numan Gorgulu,
Berna Yelken,
Turker Emre,
Aydin Turkmen,
Alaattin Yildiz,
Nilgun Aysuna,
Semra Bozfakioglu and
Mehmet Sukru Sever
Division of Nephrology, Department of Internal Medicine, Istanbul School
of Medicine, Istanbul University, Istanbul, Turkey
Correspondence to: Y. Caliskan, Istanbul School of Medicine, Department of
Internal Medicine, Division of Nephrology, Capa, Topkapi, Istanbul, Turkey.
ykcaliskan{at}yahoo.com
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ABSTRACT
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Background: The effect of pre-transplant dialysis
modality on early graft function is a matter of debate. Although some authors
deny the existence of a significant influence, others suggest that peritoneal
dialysis (PD) affects early graft function favorably, possibly by contributing
to a more physiologic water balance. In the present study, we evaluated the
influence of pre-transplant dialysis modality on early and late graft
function.
Patients and Methods: We studied 745 patients who
underwent a first renal transplantation during 1983–2006, comparing the
records of 44 PD patients [26 male; mean age: 26 ± 9 years (range:
8–56 years)] who received 36 living related and 8 cadaveric renal
transplantations with those of a control group of 44 consecutive hemodialysis
(HD) patients [26 male; mean age: 27 ± 11 years (range: 7–49
years)] for the index cases.
Results: The groups showed no significant differences
in donor type, human leukocyte antigen matching, immunosuppressive protocols,
and duration of dialysis. Also, neither group differed significantly with
regard to incidence of delayed graft function, acute tubular necrosis, wound
infection, systemic viral and bacterial infections, or acute rejection in the
early post-transplant period. In the late post-transplant period, incidences
of chronic rejection, graft failure, and malignancies were also similar.
During the follow-up period, 3 patients in the PD group experienced acute
rejection, 2 developed cytomegalovirus (CMV) disease, and 5 developed various
other infections. In the HD group, 4 patients experienced acute rejection, 1
developed CMV disease, and 8 experienced other infections. Five patients in
the PD group and one in the HD group died with functioning grafts (p
= 0.09). No differences were noted between the groups in the incidences of
post-transplant cardiovascular complications, malignancies, and diabetes
mellitus. In the PD group, 33 patients with functioning grafts are still being
followed, 6 have returned to dialysis, and 5 have died. In the HD group, 38
patients with functioning grafts are still being followed, 5 have returned to
dialysis, and 1 has died.
Conclusions: As a pre-transplant dialysis modality,
neither HD nor PD affects the outcome of renal transplantation.
KEY WORDS: Chronic allograft nephropathy; hemodialysis; post-transplant complications; renal transplantation.
Effect of pre-transplant dialysis modality on allograft and recipient
survival after renal transplantation is controversial. Some authors suggest
that peritoneal dialysis (PD) favorably affects early graft function
(1,2).
However, other studies reported equivalent or inferior results for PD patients
as compared with hemodialysis (HD) patients
(3,4).
Previous analyses also showed that increased dialysis duration before
transplantation is one of the most important factors affecting patient and
graft survival (5). In the
present study, we evaluated the influence of the pre-transplant dialysis
modality on early and late graft function in a parallel-group study. We also
compared various complications in the early and late post-transplant period
and causes of graft loss in PD and HD groups with similar dialysis time.
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PATIENTS AND METHODS
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We retrospectively analyzed data for 745 patients who had undergone a first
renal transplantation procedure between 1983 and 2006 at the Istanbul Faculty
of Medicine Transplantation Unit. For this study, preliminary consideration
was given to patients aged less than 65 years who had been on dialysis (PD or
HD) for at least 3 months before renal transplantation without a switch from
one dialysis modality to the other. Exclusion criteria for the study groups
included diabetes, history of peritonitis within the last 6 months, primary
nonfunctioning allografts, multiple organ transplants, and acute renal graft
failure caused by surgical complications. Based on the foregoing patient
selection criteria, 44 PD patients were enrolled. After selection of the PD
patient group, each PD patient was matched with one control. The controls for
each case were chosen from consecutive HD patients who received grafts during
the same period in the same center, and who were matched for age and sex. Only
2 patients in the PD group had been treated with continuous cycling PD. The
mean duration (± standard deviation) of follow-up post-transplant was
76.8 ± 43.1 months (PD) and 74 ± 50.5 months (HD).
Table 1 shows patient
characteristics and major causes of end-stage renal disease (ESRD). The
pre-transplant dialysis strategy in the HD study group was to dialyze patients
3 times weekly for 4 hours per session, using blood flow rates of
250–300 mL/min and dialysate flows of 500 mL/min. All HD patients were
dialyzed using a standard bicarbonate-containing dialysate bath (Na: 138
mmol/L; K: 1–2 mmol/L; HCO3: 33 mmol/L; Ca: 1.5 mmol/L; Mg:
0.75 mmol/L) and a biocompatible HD membrane. All received an adequate dose of
dialysis (double-pool Kt/V 
1.4). The continuous ambulatory PD (CAPD)
patients were treated with 4 daily exchanges, each using 2 L PD solution. All
PD patients were treated with glucose-containing dialysate and received an
adequate dose of dialysis. Post-transplant immunosuppression included the use
of steroids (in all patients at both 1 month and 6 months), cyclosporine A
(60% at 1 month, 55% at 6 months), tacrolimus (23% at 1 month, 25% at 6
months), mycophenolate mofetil (57% at 1 month, 59% at 6 months), and
azathioprine (42% at 1 month, 38% at 6 months). Anti-thymocyte globulin was
used as an induction therapy for cadaver-donor transplantation, and
basiliximab or daclizumab were also given to living-donor transplant patients
at high risk of rejection. All patients received antimicrobial prophylaxis
against pneumocystosis and viral and fungal infections.
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TABLE 1 Demographic and Baseline Clinical Characteristics of the Peritoneal
Dialysis (PD) and Hemodialysis (HD) Groups
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The primary endpoints of the study were graft and patient survival. The
secondary endpoints included complications in the early and long-term
post-transplant period. Delayed graft function (DGF) was defined as dialysis
required immediately after transplantation. Post-transplant acute tubular
necrosis (ATN) was defined as exclusion of other causes of DGF such as acute
rejection and technical complications. Chronic allograft nephropathy (CAN),
infection, cardiovascular disease, malignancy, and bone disease in the late
post-transplant period were also recorded as long-term post-transplant
complications. Our examinations of the patients conformed to good medical and
laboratory practices and to the recommendations of the World Medical
Association Declaration of Helsinki: Recommendations Guiding Medical Doctors
in Biomedical Research Involving Human Subjects.
STATISTICAL ANALYSIS
The statistical analysis was carried out using the SPSS software program
for Windows (version 15.0: SPSS, Chicago, IL, U.S.A.). Numeric variables are
shown as mean ± standard deviation. Numeric variables were compared
using the independent samples t-test. When distribution was abnormal,
nonparametric tests were used. Correlations between numeric parameters were
analyzed using the Spearman rho correlation test. Survival analysis was
carried out using Kaplan–Meier estimates. For differences in survival, a
log-rank test was used.
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RESULTS
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The proportion of living donor transplants in the study groups was
significantly higher than that for cadaveric renal transplantation
(Table 1). In each group, 8
patients underwent cadaveric renal transplantation. We observed no significant
differences between the groups with regard to donor type, donor age, human
leukocyte antigen (HLA) matching, and cold ischemia time
(Table 1). The largest
proportion of patients had 1 mismatch among the 3 HLA types. Patients also
underwent a virologic assessment for cytomegalovirus, Epstein–Barr
virus, hepatitis C virus, hepatitis B serum antigen, anti-hepatitis B
surface), and no significant difference was found between the two groups
(Table 1).
Figure 1 shows the overall
1-year graft and patient survival rates. The overall 1-year graft survival
rate was 95.5% in each study group [Figure
1(A)]. The overall 1-year patient survival rate was 95.5% for the
PD group and 97.7% for the HD group [Figure
1(B)]. We observed no significant difference in 1-year graft and
patient survival rates between the study groups. The graft failure definition
also included patient death with a functioning graft. A survival analysis was
not performed separately for the living- and cadaver-donor transplant patients
across the two groups because the cadaver-donor transplant patients
represented a small proportion of the entire group. After the second year, the
graft survival rate for the HD patients remained stable
[Figure 2(A)]. At the end of
the 5-year follow-up, patients on the HD modality during their ESRD course
seemed to have graft survival better than that of the patients on PD, but the
difference was not statistically significant [p = 0.07;
Figure 2(A)]. Comparison of the
Kaplan–Meier curves for 5-year patient survival between the PD and HD
patients showed no significant difference by log-rank test (p =
0.30), although the HD patients reached a better endpoint than did the PD
patients [Figure 2(B)]. Patient
survival rate for the HD patients also remained stable through the 5-year
follow-up [Figure 2(B)].
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Figure 1 — Kaplan–Meier estimates for 1-year graft and patient survival
rates. The log-rank test was used to evaluate differences in survival. (A) The
overall 1-year graft survival rate was 95.5% for the peritoneal dialysis (PD)
and for the hemodialysis (HD) group. (B) The overall 1-year patient survival
rate was 95.5% for the PD group and 97.7% for the HD group (p =
0.1).
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Figure 2 —(A) At the end of the 5-year follow-up, patients on hemodialysis
(HD) during the course of end-stage renal disease seemed to have better
survival than did the patients on peritoneal dialysis (PD), but the difference
was not statistically significant (p = 0.07). After the second year,
the graft survival rate for the HD patients remained stable over the 5 years.
(B) Comparison of the Kaplan–Meier curves for 5-year survival of former
PD and HD patients showed no significant differences by log-rank test
(p = 0.30), although the endpoint for HD was better than that for PD.
The survival rate for HD patients also remained stable over the 5 years.
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When the 1-year graft and patient survivals for the two groups were
compared separately for living-donor and cadaver-donor grafts, we observed no
significant differences (Table
2). Although patients who were on HD before undergoing
living-donor transplantation seemed to have better 5-year graft survival than
did the equivalent PD patients, the difference was not statistically
significant. The 5-year patient survival in the two groups was also
similar.
Table 2 shows the rates of
post-transplant complications in the early period in the two groups. The
overall incidence of lymphocele was 14% in both study groups. The overall
incidences of DGF and ATN in PD study group were higher than those in the HD
group, but the differences were not statistically significant. In the early
post-transplant period, acute rejection and infection rates were similar
between the two study groups. Table
2 also shows the causes of graft failure. In both study groups,
CAN was the main cause of graft failure. During the follow-up period, 3
patients in the PD group experienced acute rejection. In the PD group, the
incidence of death with functioning graft was higher than that seen in the HD
group, but the difference was not statistically significant. Recurrence of
glomerulonephritis was seen in only 1 patient on HD treatment before renal
transplantation.
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DISCUSSION
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Earlier reports mentioned that performing a prospective study in patients
with ESRD could be regarded as extremely difficult because of the advantages
and disadvantages associated with pre-transplant dialysis modality choice for
individual patients (6).
Various factors related to the transplantation procedure can affect immediate
kidney function. In the previous reports, the most important of these factors
were donor age, cold and warm ischemia times, HLA match, panel reactive
antibody (PRA) status, and recipient body weight
(7). The present parallel-group
retrospective study, in which both the HD and the PD groups were matched for
donor age, cold and warm ischemia times, HLA match, PRA status, and recipient
demographic features, showed that choice of dialysis modality before renal
transplantation did not influence patient and graft survival at 1 and 5
years.
Previous studies suggested that PD as a pre-transplantation dialysis
modality has a protective effect on recovery of renal function after renal
transplantation
(8,9),
and it was hypothesized that fluid status might be implicated in that finding
(8). The results of the present
study do not confirm previous data indicating that PD as pre-transplantation
dialysis modality might be advantageous because of a more rapid recovery of
renal function in PD patients
(1,9–11).
Acute rejection rates in the early and late post-transplant period were
similar in both study groups, although existing experimental and clinical data
suggest that patients receiving HD may be more likely to have acute rejection.
Also, several studies in adult patients have found an association between
increased graft thrombosis and prior CAPD treatment
(12). However, in the present
study, none of the patients in our PD group had allograft thrombosis.
When long-term outcome (1 year and 5 years) was studied, no difference
between dialysis modalities was reported
(13). However, in the present
study, at the end of the 5-year follow-up, patients on the HD modality during
the ESRD course seemed to have better survival than did patients on PD;
however, the difference was not statistically significant.
Previous studies comparing the rates of post-transplant complications
between PD and HD patients have produced conflicting results. The rates of
post-transplant complications (including DGF, ATN, CAN, cardiovascular
disease, avascular necrosis, recurrent glomerulonephritis, and death with
functioning graft) were similar between our PD and HD patients. The rates of
post-transplant infection were also similar between the two groups.
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CONCLUSIONS
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The choice of dialysis modality did not influence patient and graft
survival at 1 year and 5 years. Although patients on HD seemed to have better
5-year patient survival than did patients on PD, the difference was not
statistically significant. The rates of early and late post-transplant
complications were similar. As pre-transplant dialysis modalities, HD and PD
do not affect the outcome of renal transplantation.
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ABSTRACT
PATIENTS AND METHODS
