Benefits of kidney transplantation in Asians - A comparison of survival of kidney transplant recipients and wait-listed patients remaining on dialysis in Singapore
Vivek Anand 2, Quan Yao Ho1, Terence Kee Yi Shern1.
1Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore; 2Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
Background: Survival benefit of deceased donor kidney transplantation is well demonstrated in the Western world but evidence for this in Asian populations are lacking. This is a study to examine survival of Singaporeans receiving a deceased donor kidney transplant compared to wait-listed patients remaining on dialysis. As the entry criteria to be on the wait-list is much stricter in Singapore, we hypothesize that the survival benefits of kidney transplantation may be lower than that seen in the Western world.
Methods: This is a single-centre retrospective cohort study of 1088 wait-listed patients receiving a deceased donor kidney transplant or remaining on dialysis during the period of 1st Jan 1990 to 31st Dec 2013. Follow-up was based on intent to treat till 31st December 2018. Life tables were used to determine the survival with a kidney transplant versus remaining on the wait-list at 10 years. A time-dependent proportional Cox regression was used to determine survival benefit of kidney transplantation over remaining on dialysis.
Results: Mortality of deceased donor kidney transplant recipients was lower than wait-listed patients remaining on dialysis (RR 0.54; 95% CI 0.42-0.68, p<0.001). Among kidney transplant recipients, the most beneficial effect was seen in those aged under 50 (RR 0.45; 95% CI 0.34-0.59, p<0.001), males (RR 0.44; 95% CI 0.31-0.62, p<0.001), those of Chinese (RR 0.51; 95% CI 0.39-0.66, p<0.001) or Malay ethnicity (RR 0.48; 95% CI 0.24-0.96, p=0.038), and those with chronic glomerulonephritis (RR 0.49; 95% CI 0.35-0.68, p<0.001) or systemic vasculitis (RR 0.092; 95% CI 0.011-0.77, p=0.027) as the cause of end-stage renal failure. Of all patients remaining on the wait-list, 74.5% survived to 10 years, while only 41.7% of those with diabetic kidney disease survived that long.
Conclusion: Cadaveric kidney transplant recipients have better survival than those remaining on the wait-list, though this difference is smaller in Singapore as compared to other countries. This could be related to the stricter entry criteria into the wait-list where patients with history of significant cardiovascular disease and malignancy are excluded from listing. Those with diabetic kidney disease have the poorest survival on the wait-list.
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