Photo Credit: Aria sandi Hasim

While rates of waitlisting after kidney transplant failure have risen, disparities based on race, ethnicity, and sex prolong wait times for a second transplant.

Among patients who began dialysis after a first kidney allograft failed, waitlisting for re-transplantation has increased. However, rates of re-transplantation and mortality have declined, according to findings published in the American Journal of Kidney Disease.

“Over the past three decades, there have been changes in the management and outcomes of kidney transplant recipients,” researchers wrote. “Similarly, the outcomes of persons with kidney failure on dialysis have somewhat improved, although mortality remains unacceptably high. Little is known about the trends in the outcomes of patients whose kidney allograft failed.”

Jingbo Niu, MD, ScD, and colleagues examined US patients whose first kidney allograft failed between 1990 and 2019 to assess long-term trends in waitlisting, re-transplantation, and all-cause mortality after allograft failure.

Disparities Observed Following Allograft Failure

The absolute number of patients whose allograft failed and started dialysis rose from 3,197 patients in 1990 to 5,821 patients in 2019. Compared with 1990-1994, rates of waitlisting for a second transplant rose with each successive 5-year period, peaking between 2005-2009 before declining again after that.

The rate of re-transplantation following allograft failure declined by 9%, 14%, 18%, 7%, and 11% in the sequential 5-year eras; the mortality rate was also 25% lower in 2015-2019 (HR=0.75; 95% CI, 0.72-0.77) compared with 1990-1994.

Women experienced a decline in the rate of waitlisting (HR, 0.93; 95% CI, 0.91-0.95) and a reduced rate of re-transplantation (HR, 0.93; 95% CI, 0.91-0.95) compared with men. Further, Black and Hispanic patients had significantly lower rates of waitlisting, re-transplantation, and mortality compared with White patients.

The researchers also assessed transplant type. The rate of living donor transplant after first allograft failure doubled between 1990-1994 and 2000-2004 (HR=2.08; 95% CI, 1.89-2.30), but no additional increases were seen thereafter. Receiving a second transplant from a deceased donor consistently declined by approximately 30% in all eras relative to 1990-1994.

Directions for Future Research

“Although rates of waitlisting after kidney allograft failure are increasing over time, these benefits are not seen by all racial and ethnic groups, and patients are facing increasingly longer wait times for a second transplant,” Dr. Niu and colleagues wrote.

The racial, ethnic, and sex differences seen necessitate further investigation, they continued. In addition, disparities based on race, ethnicity, and sex “should be targeted in clinical education and health policy formulation so that all suitable persons can enjoy equitable access to a second kidney transplant after failure of their first one.”