Comparison of Mortality in All Patients on Dialysis, Patients on Dialysis Awaiting Transplantation, and Recipients of a First Cadaveric Transplant
Robert A. Wolfe, Ph.D., Valarie B. Ashby, M.A., Edgar L. Milford, M.D., Akinlolu O. Ojo, M.D., Ph.D., Robert E. Ettenger, M.D., Lawrence Y.C. Agodoa, M.D., Philip J. Held, Ph.D., and Friedrich K. Port, M.D.
Background The extent to which renal allotransplantation —as compared with long-term dialysis — improves survivalamong patients with end-stage renal disease is controversial,because those selected for transplantation may have a lowerbase-line risk of death.
Methods In an attempt to distinguish the effects of patientselection from those of transplantation itself, we conducteda longitudinal study of mortality in 228,552 patients who werereceiving long-term dialysis for end-stage renal disease. Ofthese patients, 46,164 were placed on a waiting list for transplantation,23,275 of whom received a first cadaveric transplant between1991 and 1997. The relative risk of death and survival wereassessed with time-dependent nonproportional-hazards analysis,with adjustment for age, race, sex, cause of end-stage renaldisease, geographic region, time from first treatment for end-stagerenal disease to placement on the waiting list, and year ofinitial placement on the list.
Results Among the various subgroups, the standardized mortalityratio for the patients on dialysis who were awaiting transplantation(annual death rate, 6.3 per 100 patient-years) was 38 to 58percent lower than that for all patients on dialysis (annualdeath rate, 16.1 per 100 patient-years). The relative risk ofdeath during the first 2 weeks after transplantation was 2.8times as high as that for patients on dialysis who had equallengths of follow-up since placement on the waiting list, butat 18 months the risk was much lower (relative risk, 0.32; 95percent confidence interval, 0.30 to 0.35; P<0.001). Thelikelihood of survival became equal in the two groups within5 to 673 days after transplantation in all the subgroups ofpatients we examined. The long-term mortality rate was 48 to82 percent lower among transplant recipients (annual death rate,3.8 per 100 patient-years) than patients on the waiting list,with relatively larger benefits among patients who were 20 to39 years old, white patients, and younger patients with diabetes.
Conclusions Among patients with end-stage renal disease, healthierpatients are placed on the waiting list for transplantation,and long-term survival is better among those on the waitinglist who eventually undergo transplantation.
Source Information
From the U.S. Renal Data System Coordinating Center (R.A.W., V.B.A.) and the Departments of Biostatistics (R.A.W., V.B.A.), Internal Medicine (A.O.O., F.K.P.), and Epidemiology (F.K.P.), University of Michigan, Ann Arbor; Brigham and Women's Hospital, Boston (E.L.M.); the Department of Pediatric Nephrology, University of California Los Angeles, Los Angeles (R.E.E.); the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md. (L.Y.C.A.); and the University Renal Research Education Association, Ann Arbor, Mich. (P.J.H.).
Address reprint requests to Dr. Wolfe at the University of Michigan, 315 W. Huron, Suite 240, Ann Arbor, MI 48103, or at bobwolfe{at}umich.edu.
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