Trends in Kidney Allograft Failure Among First-Time Transplant Recipients in the United States

Rationale & objective: The management and outcomes of kidney transplant recipients have evolved over the past 3 decades. This study of US patients whose first kidney allograft failed examined long-term trends in subsequent waitlisting, retransplantation, and all-cause mortality.

Study design: Retrospective cohort study.

Setting & participants: Patients recorded in the US Renal Data System (USRDS) whose first kidney allograft failed between 1990 and 2019.

Exposure: The 5-year period in which the allograft failure occurred: 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014, or 2015-2019.

Outcome: (1) Waitlisting for retransplantation, (2) retransplantation, and (3) all-cause mortality following first allograft failure.

Analytical approach: Competing risk survival analyses with the approach described by Fine and Gray used for the outcomes of waitlisting and retransplantation, and Cox proportional hazards models used for the outcome of all-cause mortality.

Results: The absolute number of patients whose allograft failed and who started dialysis increased from 3,197 in 1990 to 5,821 in 2019. Compared with 1990-1994, the rate of waitlisting for a second transplant increased with each subsequent 5-year period, peaking between 2005 and 2009 before decreasing again subsequently. The rate of retransplantation following allograft failure decreased by 9%, 14%, 18%, 7%, and 11% in the sequential 5-year eras; and the mortality rate was 25% lower in 2015-2019 (HR, 0.75 [95% CI, 0.72-0.77]) compared with 1990-1994. Women had a reduced rate of waitlisting (HR, 0.93 [95% CI, 0.91-0.95]) and lower rate of retransplantation (HR, 0.93 [95% CI, 0.91-0.95]) compared with men. Compared with White patients, African American and Hispanic patients had significantly lower rates of waitlisting, retransplantation, and mortality.

Limitations: Retrospective data that lacks granular clinical information.

Conclusions: During the past 3 decades, among patients whose first kidney allograft failed and subsequently initiated dialysis, the rates of waitlisting for retransplantation increased while the rates of retransplantation and mortality decreased. Disparities based on race, ethnicity, and sex in waitlisting and retransplantation were observed and warrant further investigation.

Plain-language summary: Kidney allograft failure constitutes the fourth most common cause of dialysis initiation in the United States, and it accounts for 4% to 10% of yearly new dialysis starts globally. Little is known about the trends in the outcomes of patients whose kidney allograft failed. We studied US patients whose first kidney allograft failed between 1990 and 2019 to understand trends in waitlisting for retransplantation, retransplantation, and all-cause mortality after kidney allograft failure. Among patients whose first kidney allograft failed and started dialysis, rates of waitlisting increased and rates of retransplantation and mortality decreased over the past 3 decades. We found racial, ethnic, and sex-based disparities in outcomes. Compared with White patients, African American and Hispanic patients had significantly lower rates of waitlisting, retransplantation, and mortality. Women also had lower rates of waitlisting and retransplantation compared with men.