1. ¹Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
2. ²Tufts New England Medical Center, Boston, USA
3. ³University of Alberta, Edmonton, British Columbia, Canada

Correspondence: JS Gill, Division of Nephrology, St Paul's Hospital, University of British Columbia, Providence Building, Ward 6a, 1081 Burrard Street, Vancouver, British, Columbia Canada V6Z 1Y6. E-mail: jgill@providencehealth.bc.ca

Received 24 June 2006; Revised 19 September 2006; Accepted 7 November 2006; Published online 17 January 2007.

Abstract

Analyses describing outcomes of kidney transplantation usually exclude the survival of wait-listed patients and dialysis patients with failed kidney transplants, and thus reflect only a portion of the typical transplant process. We determined death rates during the continuum of wait-listing, transplantation, and after allograft failure among adult end-stage renal disease patients in the United States between 1995 and 2003. Before transplantation, death rates increased with longer waiting times. Death rates were lowest during the period of allograft function and highest after allograft failure. Patients were at particularly high risk during periods of transition between dialysis and transplantation (death rates during the peri-transplant period and during the re-initiation of dialysis after transplant failure were 8.2/100 patient-years (95% confidence interval (CI) 7.7, 8.8) and 17.9/100 patient-years (95% CI 15.7, 20.3), respectively compared to 6.4/100 patient-years (95% CI 6.25, 6.51) during the period of wait-listing. Diabetic patients and older patients were at increased risk at all time points. The most common known cause of death in all age subgroups was cardiovascular disease. The proportion of death owing to sepsis was greatest after allograft failure (16.8% of all deaths were due to sepsis compared to 14.0% during wait-listing, and 12.7% during the period of allograft function). Consideration of the entire transplant experience as a whole should help to focus patient care on periods of particularly high risk, and emphasizes opportunities to improve outcomes by strategies aimed at preventing death owing to cardiovascular and infectious causes.