Transplant cuts death risk by half for AAV patients in kidney failure
20-year study of those on waiting list finds risk drops by 53% with surgery
Among ANCA-associated vasculitis (AAV) patients with kidney failure and waiting for a kidney transplant, undergoing the transplant reduces their risk of dying by more than half relative to continuing on dialysis, a replacement therapy.
These findings, from a 20-year study of people in France with AAV listed for a kidney transplant, “underscore the importance of routinely evaluating patients with AAV with advanced chronic kidney disease for transplant eligibility as part of their standard care,” the researchers wrote.
“Notably, a considerable number of patients on the waiting list died before receiving a transplant, highlighting the need to enhance kidney transplant accessibility” for these people, they added.
The study, “Kidney transplantation improves survival in ANCA-associated vasculitides with end-stage kidney disease,” was published in Kidney International Reports.
About one-quarter of AAV patients in kidney failure 5 years after diagnosis
People with AAV, a group of autoimmune disorders marked by inflammation and damage to small blood vessels, can develop glomerulonephritis (GN), inflammation of the kidneys’ filtering units called the glomeruli.
Disease-associated GN often leads to kidney failure — often called end-stage kidney disease — and “has a major impact on [kidney] and global survival; around 25% of patients will require kidney replacement therapy within 5 years from [AAV] diagnosis,” the researchers wrote.
Kidney replacement therapy can involve dialysis, a procedure that filters the blood when the kidneys no longer can, or a kidney transplant. While a transplant is considered the optimal treatment for end-stage kidney disease (ESKD), its survival benefits “among patients with AAV-GN–induced ESKD has not been well-studied,” the researchers wrote.
Researchers at centers across France analyzed outcomes among AAV patients with kidney failure who were started on dialysis and placed on a kidney transplant waiting list between 2002 and 2022.
Patient data was pulled from a national registry of people starting on kidney replacement therapy, called the French Renal Epidemiology and Information Network.
A total of 468 people in the registry with AAV-related end-stage kidney disease were placed on a wait list. Nearly two-thirds were males. Slightly more than half of these patients (52%) had granulomatosis with polyangiitis (GPA), while the remaining 48% had microscopic polyangiitis (MPA), the two most common types of AAV.
A total of 318 patients (68%) underwent a kidney transplant. Over a median follow-up of 61 months (about five years) since being placed on the list, nearly one-third (32%, or 148 of 468 people) died.
Researchers noted that patients who underwent a transplant were younger than those who stayed on the list over the study’s years (57 vs. 61 years old), and they had fewer comorbidities or co-existing conditions.
Causes of death similar between people given transplant and on waiting list
Deaths during follow-up were significantly fewer among patients who received a kidney transplant compared with those who did not (27% vs. 41% ). The causes of death, either infections, cancer, or cardiovascular disease, were similar between the two groups.
More kidney transplant recipients than waiting list patients were alive five years (88% vs. 67%) and 10 years (72% vs. 28%) after placement on the list, resulting in a significantly longer median survival (13.8 vs. 5.8 years). Similar survival benefits with transplant were observed in GPA and MPA patients.
Factors associated with an increased risk of death included older age at wait list placement, having MPA, not being able to walk independently, co-existing cardiovascular conditions, and breathing problems.
Statistical analyses adjusting for these factors, as well as for sex, showed that undergoing a kidney transplant significantly associated with a 53% lower risk of death.
Similar results were observed across different patient subgroups, including by sex, AAV type, age at waiting list placement (less than or more than 60 years old), and year of ESKD onset (before or after 2012).
Likewise, excluding from the analysis patients removed from the waiting list because they were too ill or unsuitable for a transplant, or had received a living donor transplant, also didn’t affect the overall results.
Despite its survival benefits, kidney transplant was linked to a higher risk of death during the first months after a transplant, followed by a lower risk over the remaining period.
Significant survival benefit seen with kidney transplant with end-stage disease
One in six (16%) transplant recipients experienced graft failure (when the transplanted kidney stops working), requiring a return to dialysis. Over time, 13% of patients had graft failure at five years and 22% by 10 years.
Leading causes of graft failure included chronic rejection (34%), followed by blood vessel complications (22%), and AAV relapse (8%). The incidence of graft failure at 10 years was similar between GPA and MPA patients (20% vs. 24%).
The number of AAV patients with ESKD onset who were added to the waiting list rose over time, with 43% listed by one year later, 76% by two years, and 97% after five years. Similarly, the rates of transplant also rose among those placed on the list, from 31% by year one, to 52% by year two, and 74% by year five.
“In this national … study of patients with ESKD due to AAV, we found that kidney transplantation was associated with a significant survival benefit,” the researchers wrote. “Timely consideration of kidney transplant should be a part of routine care for patients with AAV-ESKD, and improved access to kidney transplantation for this population may considerably improve outcomes.”
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