Renal Transplant Registry Report 2008

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1 Renal Transplant Registry Report 28 Contents:. Introduction Page 2. Summary of transplant activity Page 2 3. Graft and Patient Survival analysis Page 3 4. Acute rejection Page 24. Comparison of graft and patient outcomes between European Renal Association (ERA) countries and the Republic of Ireland Page 27

2 . Introduction This document summarises the outcome of kidney Transplantation in Ireland as it stands at the end of 28. This work is the result of the transplant activity at Beaumont Hospital and the combined care by all the renal teams across the country. Highlights of this report include; Increasing age of Transplant recipients from a median of 4 years in 2 to 47 years in 28. Progressive increase in waiting time from 6 months in 2 to 8 months in 28 Progressive decline in cold ischemic time from a mean of 2 hours in 2 to hours in 28 The expansion of LRD transplantation over the last 3 years The progressive improvement in year adult cadaveric graft survival from 87% in period to 96% in The progressive improvement in year adult cadaveric graft survival from 7% in to 77% in Excellent long term outcome of kidney pancreas transplantation Progressive decline in acute rejection post transplantation from 33% in 993 to 6.8% in 28 Results are comparable to and better to most European countries. Current kidney Transplantation is failing to meet the demand. The production of this analysis is critically dependent on centres continuing to provide long term follow up data to the Renal Transplant Registry Prof Peter J Conlon FRCPI, Consultant Nephrologist/Renal Transplant Physician Mr Patrick O Kelly MSc Renal Unit Statistician Mr David Hickey FRCSI, Consultant Transplant Surgeon

3 2. Summary of transplant activity Table.: Summary of transplant activity Category Transplanted 27 Transplanted 28 Difference +/- in 28 Total number of transplanted kidneys Number of Cadaveric kidneys Number of Living + donor kidneys Number of Simultaneous Pancreas/Kidney Number of 2-2 Combined Kidney/Liver Percentage of male 9 9 transplant recipients Percentage of 2nd or subsequent transplants Table.2: Recipient age at transplant years 2-28 Year Median age Age range

4 Figure.: Median recipient age at transplant years 2-28 Median age at transplant Table.3: Referring centre of transplant recipients Centre Number 27 % 27 Number 28 % 28 Numbers +/- in 28 BCH..7 BEAUMONT CAVAN CORK GALWAY LETTERKENNY LIMERICK MATER OLH CRUMLIN ST. JAMES.7. - SLIGO ST. VINCENTS TALLAGHT TEMPLE STREET TULLAMORE UK WATERFORD

5 Figure.2: Mode renal replacement prior to transplantation 28 8% 28% 64% Peritoneal dialysis = 28% Haemodialysis = 64% Pre-emptive = 8% Figure.3: Cause of end stage renal disease for 28 transplant recipients 7% 3% % 3% 2% 9% 2% 7% 7% 9% APKD = % Congenital = 3% Pylonephritis = 2% Diabetes 7% Glomeronephritis = 9% Hypertension = 7% Interstitial Nephritis = 2% Miscellaneous 9% Not Known = 7% Renal Vascular = 3% 4

6 Table.4: Time on dialysis and time on waiting list pool 2-28 Year Median time on dialysis (months) IQR time on dialysis (months) Median time on pool (months) IQR time on pool (months) Figure.4: Time on dialysis and time on waiting list pool 2-28 Months Median time on waiting list Median time on dialysis

7 Table.: Serum creatinine post transplant 2 28 Year Median Creatinine month Post tx. Post tx. Median Creatinine 3months Figure.: Serum creatinine post transplant 2 28 Median Creatinine year Post tx. Serum Creatinine (mmol/l) Median Creatinine month post Tx Median Creatinine year post Tx Median Creatinine 3 months post Tx 6

8 Table.6: Cold Ischaemic Time (CIT) 2 28 Year Mean CIT SD CIT Figure.6: Cold Ischaemic Time (CIT) 2 28 CIT (hours) Year 7

9 Table.7: Delayed graft function post transplant (defined as the need for dialysis) 2 28 Year Number DGF (%) 2 (7.9) 2 7 (3.7) (.9) 23 2 (.7) 24 2 (4.2) 2 8 (4.) 26 2 (4.) 27 8 (2.3) 28 2 (7.2) Figure.7: Delayed graft function post transplant 2 28 % Delayed Graft Function

10 Table.8: Donor cause of death 2 28 Year Number Trauma (%) Number Non Trauma (%) 2 4 (43) 73 (7) 2 46 (38) 76 (62) 22 6 (42) 82 (8) 23 (4) 79 (9) (3) 68 (47) 2 63 () 64 () (3) 92 (6) 27 2 (37) 89 (63) (32) 93 (68) Figure.8: Donor cause of death % donor cause of death Trauma Non Trauma Table.9: Donor age 2 28 Year Median donor age Inter-quartile range 2 39 [2-47] 2 3 [22-47] [2-46] [2-47] 24 3 [24-48] 2 42 [2 - ] [26-3] 27 4 [27-3] [28-4] 9

11 Figure.9: Donor age 2 28 Median donor age Table.: Donor gender 2 28 Year Number Male donors (%) Number Female donors (%) 2 8 (64) 4 (36) 2 6 () 6 () (67) 46 (33) (6) 2 (39) (7) 62 (43) 2 7 (6) 6 (44) () 69 (49) () 62 (4) (6) 6 (44) Figure.: Donor gender % donor gender Male Female

12 Table.: Tacrolimus levels post transplant Table.2: Mean HLA miss matches 2 28 year Mean hla (std. dev.) Number miss matches (% of total) Number 222 miss matches (% of total) (.29) 3.3 (.3) 2.7 (.38) 3. (.44) 3. (.47) 3. (.37) 3. (.4) 3.2 (.9) 3. (.49) 6 (4.7) 2 (.6) (6.9) 8 (6.) 9 (6.) (3.9) 2 (8.3) 2 (8.2) 9 (6.2) 4 (3.) (4.) (.7) (3.7) (3.4) 6 (4.6) 7 (4.8) 6 (4.) (3.4) Total 3. (.44) 73 (.9) 44 (3.) Table.: Mean HLA miss matches 2 28 Mean HLAMM Year

13 Table.3: Living related donor transplants (LRD) 2 28 Year transplanted Frequency Percent of total transplants Mean age of LRD recipient (Std. Dev.) (7.8) 43. (4.8) (.) 2.7 (.6) 2.8 (7.) 34. (22.) 32.6 (2.7) Total (7.) Figure.2: Number of LRD transplants Number of living related transplants

14 3. Graft and Patient Survival analysis Adult cadaveric graft outcome Table 2.: Overall median adult cadaveric graft survival No of patients Median graft survival (years) [9% C.I.] [.6 2.] Table 2.2: Estimated adult cadaveric graft survival Follow up time (years) Estimated graft survival [9% C.I.] [ [73.6. [ [34.92 Figure 2.: Kaplan-Meier adult cadaveric graft survival estimates 7 % survival Time (years) 3

15 Table 2.3: Cox proportional Hazards graft survival model for adult cadaveric kidneys Variables HR [9% conf. int] P value Recipient age.6 [. -.22] <. Donor age. [. -.2] <. Recipient sex.4 [.9 -.2].9 Transplant number.4 [.2 -.9]. Donor sex.894 [ ].9 CIT. [ ].388 HLA miss matches.98 [ ].466 Delayed graft function.24 [.2 -.].38 Acute rejection (3 month).282 [ ]. Era transplanted*.828 [ ]. Tachrolimus.92 [ ].3 MMF.32 [ ].867 * Eras used = , , , Table 2.4: Logistic regression model to test for effect on delayed graft function for adult cadaveric kidneys Variables Odds ratio [9% conf. int] P value Recipient age Donor age Recipient sex Donor sex Era transplanted CIT Transplant number HLA miss matches.7 [ ].38 [.27 -.].6 [ ].33 [ ].497 [ ].62 [ ].996 [ ].97 [ ].23 < <. <

16 Paediatric cadaveric Graft outcome Table 2.: Overall median paediatric cadaveric graft survival No of patients Median graft survival (years) [9% C.I.] 88.9 [ ] Table 2.6: Estimated paediatric cadaveric graft survival Follow up time (years) Estimated graft survival [9% C.I.] 8.8 [ ] 7.4 [ ].86 [ ] [ ] Figure 2.2: Kaplan-Meier paediatric cadaveric graft survival estimates 7 % survival Time (years)

17 Simultaneous Pancreas Kidney (SPK) Graft outcome Table 2.7: Overall medianspk cadaveric graft survival No of patients Median graft survival (years) [9% C.I.] 94.6 [ 8.9 not defined] Table 2.8: Estimated SPK cadaveric graft survival Follow up time (years) Estimated graft survival [9% C.I.] 94.6 [ ] 83.2 [ ] 6.38 [ ] [ ] Figure 2.3: Kaplan-Meier SPK cadaveric graft survival estimates % survival Time (years) 6

18 Graft survival adult cadaveric st, 2 nd, 3 rd Table 2.9: overall median graft survival for cadaveric adult st, 2 nd & 3 rd Transplant number No of patients Median graft survival (years) [9% C.I.],9.4 [.6 2.2] [.2 3.7] 3 7. [ 4.7.3] grafts Table 2.:Estimated cadaveric adult st,2 nd & 3 rd graft survival Transplant number Follow up time Estimated graft survival [9% C.I.] (years) [ ] 7.29 [ ].9 [ ] [ ] [ ] [ ] 8.3 [ ] [ ] 88. [ ] 63.2 [ ] [ ] [ ] Figure 2.4: Kaplan-Meier cadaveric adult st, 2 nd & 3 rd graft survival estimates 7 % survival Time (years) First transplant Third transplant Second transplant 7

19 Graft survival adult cadaveric by four time periods transplanted Table 2.: adult cadaveric graft survival by era transplanted at,, & years Follow up time (years) Period transplanted Estimated graft survival [9% C.I.] [ ] 68.8 [ ] 47.4 [ ] [ ] Figure 2.: adult cadaveric graft survival by era transplanted [ ] 7.66 [ ] 3.3 [ ] 89.3 [ ] 77.8 [ ] 96.3 [ ] 7 % survival Time (years)

20 Graft survival paediatric cadaveric by era Table 2.2: Paediatric cadaveric graft survival by era transplanted at,,& years Follow up time (years) Period transplanted Eestimated graft survival [9% C.I.] [ ] 6.36 [ ] [ ] [ ] [ ] [ ] 8.8 [ ] [ ] [ ] [ ] Figure 2.6: Paediatric cadaveric graft survival by era transplanted at,,& years 7 % survival Time (years)

21 Patient survival adult cadaveric (From time of first graft) Table 2.3: Estimated adult cadaveric patient survival at,,& years Follow up time (years) Estimated patient survival [9% C.I.] 9.8 [ ] 87.6 [ ] 7.2 [ ] 6.9 [ ] Table 2.4: Cox proportional Hazards patient survival model for adult cadaveric transplants Variables HR [9% conf. int] P value Recipient age Donor age Recipient sex Donor sex CIT HLA miss matches Delayed graft function Acute rejection (3 month) Era transplanted Tachrolimus MMF.6 [ ]. [.4 -.8].4 [ ].4 [ ].894 [ ]. [ ].98 [ ].24 [ ].282 [ ].828 [ ].92 [ ] < Figure 2.7: Kaplan-Meier adult cadaveric patient survival estimates 7 % survival Time (years) 2

22 Patient survival paediatric cadaveric Table 2.: Estimated paediatric cadaveric patient survival at,,& years Follow up time (years) Estimated patient survival [9% C.I.] 96.9 [ ] 94. [ ] 9.82 [ ] [ ] Figure 2.8: Kaplan-Meier paediatric cadaveric patient survival estimates 7 % survival Time (years) 2

23 Patient survival SPK Table 2.6: Estimated SPK patient survival at,,& years Follow up time (years) Estimated patient survival [9% C.I.] 9.3 [ ] [ ] 74.6 [ ] 49.6 [ ] Figure 2.9: Kaplan-Meier SPK patient survival estimates 7 % survival Time (years) 22

24 Patient survival adult cadaveric by era Table 2.7: Adult cadaveric patient survival by era transplanted at,, & years Follow up time (years) Period transplanted Estimated patient survival [9% C.I.] [ ] 83. [ ] 68. [ ] 6.44 [ ] [ ] 86.7 [ ] [ ] 9.37 [ ] 88. [ ] 98.2 [ ] Figure 2.: Adult cadaveric patient survival by era transplanted at,, & years 7 % survival Time (years)

25 4. Acute rejection Acute rejection is defined as either a biopsy proven Type or Type 2 acute cellular rejection, vascular rejection and/or the need for an empirical treatment for acute rejection within the first 3 months of transplantation. Table 3.: Acute rejection rate by year era transplanted ERA Number transplanted Number of acute rejection patients % acute rejection Figure 3.: Percent acute rejection by era transplanted % acute rejection Table 3.2: Acute rejection rate by year transplanted 2 28 Year Number Number of acute % acute rejection transplanted rejection patients

26 Figure 3.2: Acute rejection rate by year transplanted %acute rejection Table 3.3: Acute rejection by intention to treat therapy adult patients Immunosuppressant Number transplanted Number of acute rejection % acute rejection CYA DC CYA DC A CYA DC A / ATG CYA MMF DC CYA RAP DC FK DC A FK DC A / ATG FK MMF DC FK MMF DC / ATG FK MMF DC / SIM patients Figure 3.3: Acute rejection by intention to treat therapy adult patients CYA DC CYA DC A CYA DC A / ATG CYA MMF DC CYA RAP DC FK DC A FK DC A / ATG FK MMF DC FK MMF DC / ATG FK MMF DC / SIM % acute rejection 2

27 Table 3.4: Acute rejection by intention to treat therapy paediatric patients Immunosuppressant Number transplanted Number of acute rejection % acute rejection CYA DC CYA DC A CYA DC A / ATG FK DC A FK DC A / ATG FK MMF DC FK MMF DC / ATG FK MMF DC / SIM patients Figure 3.4: Acute rejection by intention to treat therapy paediatric patients CYA DC CYA DC A CYA DC A / ATG FK DC A FK DC A / ATG FK MMF DC FK MMF DC / ATG FK MMF DC / SIM % acute rejection 26

28 . Comparison of graft and patient outcomes between European Renal Association (ERA) countries and the Republic of Ireland Introduction The ERA Registry collects data on renal replacement therapy (RRT) via the national and regional renal registries in Europe. For this section comparisons are made between 6 ERA countries and the Republic of Ireland which is not affiliated to ERA. Data was gleaned from the 27 ERA report (updated in June 29). There are 9 regions of Spain with separate results. Included in this report are the 3 largest regions by population, Andalusia, Catalonia and Valencia. The countries are listed in tables 4. and 4.2. Statistical analysis Unadjusted survival probabilities were calculated using the Kaplan-Meier method. In this section, patient survival after the first transplant, and graft survival after the first transplant are presented in tables and graphs by age, gender and cause of renal failure. Survival probabilities are presented as percentages from to. For the analysis of survival data two five-year cohorts were used: , one and five-year survival probabilities. 2-2, one- and two-year survival probabilities. For patient survival from first graft, event is defined as death of patient. Censoring is at loss to follow-up and end of follow-up time. For graft survival from first graft, event is defined as death of patient or graft loss. Censoring is at loss to follow-up and end of follow-up time. 27

29 Table 4.: Rates of transplantation per million populations for ERA countries and the Republic of Ireland for the year 27 Country Deceased Living Unknown Total donors Donors Source Austria Belgium Denmark Finland Greece Iceland Italy Norway Romania Spain, Andalusia Spain, Catalonia Spain, Valencia region Sweden Netherlands England Northern Ireland Scotland Wales Republic of Ireland Figure 4.: Total rates of transplantation per million populations for ERA countries and the Republic of Ireland for the year 27 Renal transplants per million population Romania Italy Greece Iceland NorthernIreland Denmark Finland Republic of Ireland Scotland Wales England Belgium Sweden Spain, Andalusia Spain, Valencia Austria Netherlands Norway Spain, Catalonia 28

30 Table 4.2: Percentages of renal replacement therapy for ERA group of countries and the Republic of Ireland Country % Transplant % HD % PD % Other Austria Belgium Denmark Finland Greece Iceland Italy Norway Romania Spain, Andalusia Spain, Catalonia Spain, Valencia region Sweden Netherlands England Northern Ireland Scotland Wales Republic of Ireland Figure 4.2: Percentages of renal replacement therapy with a functioning transplant for ERA group of countries and the Republic of Ireland Prevalent % on RRT with functioning transplant Romania Greece Italy Wales Spain, Valencia Belgium Denmark England NorthernIreland Spain, Andalusia Scotland Austria Spain, Catalonia Republic of Ireland Sweden Netherlands Finland Iceland Norway 29

31 Table 4.3: Patient survival from first cadaveric transplant Group Rep. of Ireland One year Survival in % ERA countries One year Survival in % (9% CI) (9% CI) (9% CI) ( ) 97.7 ( ) 93. ( ) 92.9 ( ) 97.9 ( ) 97.8 ( ) 94.9 ( ) 89. ( ) Rep. of Ireland Five year Survival in % 93. ( ) 9.9 ( ) 83.6 ( ) 64.3 ( ) ERA countries Five year Survival in % (9% CI) 9.2 ( ) 93. ( ) 84. ( ) 69.6 ( ) Men Women 94. ( ) 96. ( ) 9.4 ( ) 96. ( ) 86.4 ( ) 9.9 ( ) 86.3 ( ) 87.2 ( ) Diabetes Hypertension Glomerulonephritis Othercause 9. ( ) 94. ( ) 96.8 ( ) 94.9 ( ) 94. ( ) 93.3 ( ) 96.7 ( ) 9.9 ( ). ( ) 74. (9.-84.) 94.3 ( ) 9. ( ) 8.8 ( ) 8.9 ( ) 89.4 ( ) 87.6 ( ) All 9. ( ) 9.6 ( ) 88.2 (8.-9.7) 86.6 ( ) Figure 4.3: One-year Patient survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA counries 3

32 Figure 4.4: Five-year Patient survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA countries Table 4.4: Patient survival from first cadaveric transplant 2 2 Group Rep. of Ireland One year Survival in % ERA countries One year Survival in % (9% CI) (9% CI) (9% CI) (9.-99.) 9.9 ( ) 9.4 ( ) 98. ( ) 98.2 ( ) 9. (94.-9.) 88.7 (87.-9.) Rep. of Ireland Two year Survival in % 97. ( ) 94. ( ) 86. ( ) ERA countries Two year Survival in % (9% CI) 97. ( ) 97.4 ( ) 92. ( ) 84.7 ( ) Men Women 97. ( ) 9.4 ( ) 9.4 ( ) 96. ( ) 96. ( ) 93.9 ( ) 93. ( ) 94. ( ) Diabetes Hypertension Glomerulonephritis Othercause 86.7 ( ) 94. ( ) 98.4 ( ) 97.4 ( ) 93. ( ) 93. ( ) 96.7 ( ) 96.2 ( ) 83.3 ( ) 86.3 ( ) 98.4 ( ) 96. ( ) 9.6 ( ) 9. ( ) 9.6 ( ) 94.3 ( ) All 96.7 ( ) 9.6 ( ) 9.2 ( ) 93.7 ( ) 3

33 Figure 4.6: One-year Patient survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA countries Figure 4.7: Two-year Patient survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA countries 32

34 Table 4.: Graft survival from first cadaveric transplant Group Rep. of Ireland One year Survival in % (9% CI) ERA countries One year Survival in % (9% CI) -9 years 2-44 years 4-64 years 6+ years 87. ( ) 92.2 ( ) 84. ( ) 83.3 ( ) 89.9 ( ) 9. ( ) 89.8 (89.-9.) 84. ( ) Rep. of Ireland Five year Survival in % (9% CI) 7.7 ( ) 8.2 ( ) 74. ( ) 7. ( ) ERA countries Five year Survival in % (9% CI) 78.9 ( ) 8.6 ( ) 76. ( ) 64.3 ( ) Men Women 87.4 ( ) 88.4 ( ) 9.3 ( ) 89. ( ) 7. ( ) 76.3 ( ) 77.4 ( ) 77.7 ( ) Diabetes Hypertension Glomerulonephritis Other cause 8. ( ) 9. ( ) 88.6 (8.-93.) 87.3 (83.-9.) 9.4 ( ) 86.6 ( ) 9. (9.-92.) 9. ( ). ( ) 68. ( ) 78.9 (7.-8.) 77. ( ) 7.7 ( ) 72. (7.-74.) 78.7 ( ) 78.4 ( ) All 87.8 ( ) 9. (89.-9.) 7. ( ) 77. ( ) Figure 4.8: One-year Graft survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA countries 33

35 Figure 4.9: Five-year Graft survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA countries Table 4.6: Graft survival from first cadaveric transplant 2 2 Group Rep. of Ireland One year Survival in % (9% CI) ERA countries One year Survival in % (9% CI) -9 years 2-44 years 4-64 years 6+ years 97.9 ( ) 96. ( ) 9.2 ( ) 88. ( ) 9.2 ( ) 92. ( ) 89.7 ( ) 82.2 ( ) Rep. of Ireland Two year Survival in % (9% CI) 9.7 ( ) 9.6 ( ) 89.4 ( ) 82.7 ( ) ERA countries Two year Survival in % (9% CI) 89. ( ) 9. ( ) 86.6 ( ) 77. ( ) Men Women 94.4 ( ) 9.8 ( ) 89.9 ( ) 9. ( ) 92.6 ( ) 9.3 ( ) 87. ( ) 87.2 ( ) Diabetes Hypertension Glomerulonephritis Othercause 8. (6.8-9.) 92.2 ( ) 96.9 ( ) 93.6 ( ) 89.6 ( ) 87. ( ) 9. (9.-9.9) 9. ( ) 8. (6.8-9.) 84.3 (7.-9.8) 96. ( ) 92.3 ( ) 86. ( ) 82.6 ( ) 88.6 ( ) 87.4 ( ) All 93. ( ) 9. ( ) 9.7 ( ) 87. ( ) 34

36 Figure 4.: One-year Graft survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA countries Figure 4.: Two-year Graft survival from first cadaveric transplant % survival years 2-44 years 4-64 years 6+ years Men Women Diabetes Hypertension Glomerulonephritis Othercause ESRD All Republic of Ireland ERA countries 3

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