Predictors of long‐term primary cadaveric renal transplant survival

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Abstract
The factors which predict long‐term kindey allograft survival have been difficult to determine due to the reliance on multi‐center data. A retrospective review of the post‐transplant course of 665 consecutive primary cadaveric (CAD) kidney transplants performed at a single center over an 8‐ycar period was performed in an attempt to identify what demographic, immunologic and post‐transplant factors are important in predicting long‐term kidney graft function. All recipients were treated with a uniform management strategy including sequential quadruple immunosuppression and histologic confirmation of all episodes of graft dysfunction. The average length of follow‐up was 56 months and no patient had less than 12 months of follow‐up. Actuarial 8‐year (yr) patient and graft survival was 76% and 57% respectively. Exclusion of 64 patients who died with a functioning graft from non‐transplant related cause resulted in an improvement of 8‐yr graft survival to 71%. Evaluation of factors predicting long‐term graft survival with Cox analysis demonstrated that the presence of ONE or greater than ONE (>ONE) rejection episode (relative risk [RR] = 6.45), diabetes mellitus (RR = 1.72), and black race (RR= 1.31) were independent risk factors for graft loss. Censored graft survival for patients with NONE, ONE, or >ONE rejection episodes was 83%, 69% and 45% respectively. Rejection episodes occurred in 47% of recipients. Two‐third of rejection episodes occurred before 60 days and acute rejection episodes were rare after 1 yr. No immunologic factors including sex, current or maximum PR A, HLA mismatch, race or presence of diabetes mellitus predicted the risk of developing ONE or >ONE rejection episodes. These data suggest that patients wihout an episode of acute rejection have excellent long‐term graft survival regardless of demographic or immunologic risk‐factors pre‐transplant. The presence of ONE or >ONE rejection episode is the most important determinant of long‐term renal allograft survival. Attempts to prevent rejection episodes should focus on better immunosuppression, and not on better matching, in recipients of first CAD kidney transplants.