CHAPTER 5 RENAL TRANSPLANTATION. Editor: Rosnawati Yahya. Expert Panels: Hooi Lai Seong Ng Kok Peng Suryati Binti Yakaob Wong Hin Seng.

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1 CHAPTER 5 Editor: Roswati Yahya Expert Panels: Hooi Lai Seong Ng Kok Peng Suryati Binti Yakaob Wong Hin Seng Contents 5. Stock and Flow of Rel Transplantation Stock and Flow Transplant Rates 5.2 Recipients Characteristics Demographics, Clinical and Serology Status Primary Causes of ESRF 5.3 Transplant Practices Type of Transplant Place of Transplant 5.4 Transplant Outcomes Post Transplantation Complications Biochemical Outcome Deaths and Graft Loss 5.5 Patient and Graft Survival 5.6 Cardiovascular Risk in Rel Transplant Recipients 5.7 QoL Index Score in Rel Transplant Recipients

2 Twelfth Report of the Natiol Transplant Registry 25 List of Tables Table 5..: Stock and flow of rel transplantation, Table 5..2: New transplant rate per million population (pmp), Table 5..3: Transplant prevalence rate per million population (pmp), Table 5..4: Place of transplantation, Table 5.2.: Rel transplant recipients characteristics, Table 5.2.2: Primary causes of end stage rel failure, Table 5.3.: Type of rel transplantation, Table 5.3.2: Biochemical data, Table 5.3.3: Immunosuppressive Medications, Table 5.3.4: Non immunosuppressive medications, Table 5.4.: Post transplant complications, Table 5.4.2: Transplant patient death rate and graft loss, Table 5.4.3: Causes of death in transplant recipients, Table 5.4.4: Causes of graft failure, Table 5.5.(a): Patient survival, Table 5.5.(b): Risk factors for transplant patient survival Table 5.5.2(a): Graft survival, Table 5.5.2(b): Risk factors for transplant graft survival Table 5.5.3: Udjusted patient survival by type of transplant, Table 5.5.4: Graft survival by type of transplant, Table 5.5.5(a): Patient survival by year of transplant (Living related transplant, 26-25)... 2 Table 5.5.5(b): Graft survival by year of transplant (Living related transplant, 26-25)... 2 Table 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 26-25)... 2 Table 5.5.6(b): Graft survival by year of transplant (commercial cadaver transplant, 26-25) Table 5.6.: Risk factors for IHD in rel transplant recipients at year Table 5.6.2(a): Systolic BP, Table 5.6.2(b): Diastolic BP, Table 5.6.3: CKD stages, Table 5.6.4: BMI, Table 5.6.5(a):LDL, Table 5.6.5(b):Total cholesterol, Table 5.6.5(c): HDL, Table 5.6.6(a): Treatment for hypertension, Table 5.6.6(b): Distribution of systolic BP without antihypertensives, Table 5.6.6(c): Distribution of diastolic BP without antihypertensives, Table 5.6.6(d): Distribution of systolic BP on antihypertensives, Table 5.6.6(e): Distribution of diastolic BP on antihypertensives, Table 5.7.: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients Table 5.7.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients

3 Twelfth Report of the Natiol Transplant Registry 25 List of Tables ( cont.) Table 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients Table 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients Table 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients List of Figures Figure 5..: Stock and flow of rel transplantation, Figure 5..2 (a): New transplant rate, Figure 5..2 (b): Transplant prevalence rate, Figure 5..4(a): Places of transplantation, Figure 5..4(b): Place of transplantation within Malaysia... 6 Figure 5.4.2(a): Transplant recipient death rate, Figure 5.4.2(b): Transplant recipient graft loss rate, Figure 5.5.(a): Patient survival, Figure 5.5.2(a): Graft survival, Figure 5.5.3: Patient survival by type of transplant, Figure 5.5.4: Graft survival by type of transplants, Figure 5.5.5(a): Patient survival by year of transplant (Living related transplant, 26-25)... 2 Figure 5.5.5(b): Graft survival by year of transplant (Living related transplant, 26-25)... 2 Figure 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 26-25) Figure 5.5.6(b): Graft survival by year of transplant (Commercial cadaver transplant, 26-25) Figure 5.6.(a): Venn diagram for pre and post transplant complications (in %) at year Figure 5.6.(b): Venn diagram for pre and post transplant complications (in %) at year Figure 5.6.(c): Venn diagram for pre and post transplant complications (in %) at year Figure 5.6.(d): Venn diagram for pre and post transplant complications (in %) at year Figure 5.6.(e): Venn diagram for pre and post transplant complications (in %) at year Figure 5.6.2(a): Systolic BP, Figure 5.6.2(b): Diastolic BP, Figure 5.6.3: CKD stages by year Figure 5.6.4: BMI, Figure 5.6.5(a): LDL, Figure 5.6.5(b): Total cholesterol, Figure 5.6.5(c): HDL,

4 Twelfth Report of the Natiol Transplant Registry 25 List of Figures ( cont.) Figure 5.7.: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients Figure 5.7.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients Figure 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients Figure 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients Figure 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients

5 Twelfth Report of the Natiol Transplant Registry STOCK AND FLOW The number of new transplant patients decreased from 5 in 26 to its lowest in 24 with only 9 transplant surgeries performed in 24. This substantial reduction in the number of new transplants was predomintly due to reduction in the number of transplantation performed overseas. The number of new transplants improved by 4% with 4 transplants performed in 25. The number of functioning rel transplants had increased by 8% from 774 in 26 to 98 in 2 and declined from 2 onwards with 845 functioning rel transplant in 25 (Table 5..). Despite advances in immunosuppression, the rate of allograft failure remained the same with 2-3% of allograft loss every year. Table 5..: Stock and flow of rel transplantation, New transplant patients Died Graft failure Lost to Follow up Functioning graft at 3 st December Figure 5..: Stock and flow of rel transplantation, New patients Functioning graft at 3st Dec 2,,8,6 No. of patients,4,2, The incidence rate of rel transplantation declined from 6 per million population in 26 to 3 per million population in 23 and had remained static in the last three years (Table & Figure 5..2). This is extremely low in comparison to Australia and New Zealand, which reported 37 and 27 per million population in 2. Table 5..2: New transplant rate per million population (pmp), New transplant patients New transplant rate, pmp Table 5..3: Transplant prevalence rate per million population (pmp), Functioning graft at 3 st December Transplant prevalence rate, pmp

6 Twelfth Report of the Natiol Transplant Registry 25 The transplant prevalence rate continue to drop over the last years at 66 per million population in 26 to 6 per million population in 25 (Table & Figure 5..3). Figure 5..2 (a): New transplant rate, Rate, pmp Figure 5..2 (b): Transplant prevalence rate, Rate, pmp New Transplant rate, pmp Transplant Prevalence rate, pmp Transplantation in local centers increased with 5 transplants performed in 26, increasing to 85 transplants in 2. Unfortutely, this increase was not sustained and the number of rel transplants performed in local centers has remained static in 22 and 23. This is disturbing data as it underscores our failure to improve rate of transplantation within the country, which is mainly due to the lack of both living as well as cadaveric donors. It is encouraging to see that the number of transplants performed in Chi continued to drop from 87 cases (57.6%) in 26 down to cases (. %) in 23. Unfortutely, the figure rose to 4 cases (3.5%) in 25. It is worrying to see the number of transplants performed in other overseas centres increased with 8 cases reported in 25 (Table 5..4 and Figure 5..4 (a)). The number of transplants performed in Hospital Kuala Lumpur had remained static at 36 to 39 per year with a drop to 27 in 2 (Table 5..4 and Figure 5..4 (b)). Figure 5..4(a): Places of transplantation, Figure 5..4(b): Place of transplantation within Malaysia 6 Local Other overseas Chi Unknown India 4 HKL PPUKM Prince Court UMMC Selayang Hospital Other local Number

7 Twelfth Report of the Natiol Transplant Registry 25 Table 5..4: Place of transplantation, HKL PPUKM Prince Court Medical Centre UMMC Selayang Hospital Other local Chi India Other overseas Unknown Total HKL PPUKM Prince Court Medical Centre UMMC Selayang Hospital Other local.8.9 Chi India Other overseas Unknown Total

8 Twelfth Report of the Natiol Transplant Registry RECIPIENTS CHARACTERISTICS Over the last years, the age of transplant recipients had remained unchanged, with a mean between 36 to 42 years old. Male patients continued to predomite with 59 to 69% of the recipients. Over the last ten years, the proportion of diabetic patients who underwent rel transplantation decreased slowly, 8% in 26 and only 2% in 25. This coincided with the drop in Chi transplants where the majority of the diabetic patients underwent their transplantation. Patients with hepatitis B had decreased from 7% earlier to -4% in the last 3 years. Patients with hepatitis C showed initial reduction from 8-9% in 26 to 27, reduced to % in 22 and slowly increasing again to 5% in 25 In terms of underlying cause of end stage rel failure (Table 5.2.2), the commonest cause was glomerulonephritis (GN), followed by hypertension and diabetes. The proportion of transplant recipients having end stage rel disease due to unknown causes had decreased from 44% in 26 to 9% in 25. Table 5.2.: Rel transplant recipients characteristics, New Transplant Patients Age at transplant (years), Mean Age at transplant (years), SD % Male % Diabetic (co-morbid/ primary rel disease) % HBsAg positive % Anti-HCV positive Table 5.2.2: Primary causes of end stage rel failure, New transplant patients Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy Hereditary nephritis Unknown Others New transplant patients Glomerulonephritis Diabetes Mellitus Hypertension Obstructive uropathy ADPKD Drugs/ toxic nephropathy 2 2 Hereditary nephritis 2 2 Unknown Others

9 Twelfth Report of the Natiol Transplant Registry TRANSPLANT PRACTICES 5.3. Type of rel transplantation The proportion of commercial transplantation had gradually reduced significantly from 63.4% in 26 to.9% in 25. This was predomintly due to the marked decline in commercial cadaveric transplantation (56.7% in 26 to.% in 25). There was an increasing number of commercial living transplantation from 6.7% in 26, peaked at 26.% in 2 and declined to 9.8% in 25. Local cadaveric transplantation made up 55.4% of transplants (5 recipients) in 25, which was the highest number seen in the last ten years. Local living donor transplantation had shown an initial rise from 29 transplants in 24, peaked at 63 transplants (67.3%) in 23. Unfortutely, this rise was not sustained and the number of local living donor transplants dropped to 33 (39.3%) recipients in 24 and 3 (33.7%) in 25. The year 27 marked the first time where there were more local transplants (55%) compared to overseas commercial transplants (45%). Since then, the proportion of local transplants continued to rise with 92.5% of the total transplantation performed locally in 23 and 89.% in 25. Table 5.3.: Type of rel transplantation, Commercial cadaver Commercial live donor Live donor (genetically related) Live donor (emotiolly related) Cadaver Total Commercial cadaver Commercial live donor Live donor (genetically related) Live donor (emotiolly related) Cadaver Total *Commercial Cadaver (Chi, India, other oversea) *Commercial live donor (living unrelated) *Cadaver (local) 9

10 Twelfth Report of the Natiol Transplant Registry Biochemical data Table summarised the biochemical data for all the transplant recipients from 2 to 25. Table 5.3.2: Biochemical data, 2-25 Biochemical parameter Summary Creatinine, umol/l n Mean SD Median Minimum Maximum Hb, g/dl n Mean SD Median Minimum Maximum Albumin, g/l n Mean SD Median Minimum Maximum Calcium, mmol/l n Mean SD Median Minimum Maximum Phosphate, mmol/l n Mean..... SD Median..... Minimum Maximum Alkaline phosphate (ALP), U/L n Mean SD Median Minimum Maximum ALT, U/L n Mean SD Median Minimum Maximum Total cholesterol, mmol/l n Mean SD Median Minimum Maximum LDL cholesterol, mmol/l n Mean SD Median Minimum.9.9.9

11 Twelfth Report of the Natiol Transplant Registry 25 Table 5.3.2: Biochemical data, 2-25 ( cont.) Biochemical parameter Summary Maximum HDL cholesterol, mmol/l n Mean SD Median Minimum Maximum Systolic blood pressure, mmhg n Mean SD Median Minimum Maximum Diastolic blood pressure, mmhg n Mean SD Median Minimum Maximum

12 Twelfth Report of the Natiol Transplant Registry Immunosuppression Medications Majority of patients were on combition immunosuppressions. Calcineurin-inhibitor based therapy remained the mainstay of immunosuppressive therapy with 48% of patients receiving it in 25. Cyclosporin was the most widely used calcineurin inhibitors until 24. However, there was a gradual decline in cyclosporine usage with 55% in 2 to 4% in 25 which coincided with increasing use of tacrolimus, with 37% in 2 to 42% in 23 and 48% in 23. The usage of anti-proliferative agents have shown similar trend over the last 5 years. The used of azathioprine continue to decline from 8% in 2 to 2% in 25. The use of mycophenolic acid fluctuated between 64 to 68% in the last 5 years. (Figure 5.3.3) The use of proliferation sigl inhibitor (PSI) has increased from 4 % in 2 to 7% in 25. Table 5.3.3: Immunosuppressive Medications, 2-25 Medication data All (i) Immunosuppressive drug(s) treatment Prednisolone Cyclosporin A Single drug treatment Tacrolimus (FK56) Azathioprine 2 2 MPA PSI 4 2 Others Combined drug treatment Medication data All (i) Immunosuppressive drug(s) treatment Prednisolone Cyclosporin A Tacrolimus (FK56) Azathioprine MPA PSI Others 2 2

13 Twelfth Report of the Natiol Transplant Registry Non immunosuppression medications In terms of non-immunosuppressive medications, calcium channel blockers are the most commonly used antihypertensive as a single or combition agent contributing to 64% of usage. This is followed by beta blockers with 42% of patients on it either alone or in combition with other medications. The use of ACE inhibitors or angiotensin receptor blocker or both showed a slight increase over the last 5 years; 3% of patients were on ACE inhibitors or angiotensin II receptor blockers (AIIRB) or both in 2 and this increased to 42 % in 23 and 4% in 25. Table 5.3.4: Non immunosuppressive medications, 2-25 Single drug treatment Medication data All Non Immunosuppressive drug(s) treatment Alpha blocker Beta blocker Calcium channel blocker ACE inhibitor ARBs Anti-lipid 3 Other antihypertensive Combined drug treatment Medication data All Non Immunosuppressive drug(s) treatment Alpha blocker Beta blocker Calcium channel blocker ACE inhibitor ARBs Anti-lipid Other antihypertensive

14 Twelfth Report of the Natiol Transplant Registry TRANSPLANT OUTCOMES 5.4. Post transplant complications In the year 25, 53% of patients were hypertensive prior to transplantation and 3% developed hypertension post transplantation. In terms of cardiovascular and cerebrovascular disease, 2% had either or both prior to transplant and another 2% developed these complications post transplantation. Cancer remains uncommon both before and after transplantation. About 3-4% of patients had diabetes pre transplant and another 6-8% of patients developed post transplant diabetes mellitus. Table 5.4.: Post transplant complications, 2-25 All patients Diabetes (either as primary rel disease or comorbid) Cancer Pre transplant N % n % n % n % n % Cardiovascular disease + cerebrovascular disorder Hypertension All patients Diabetes (either as primary rel disease or comorbid) Cancer 22 N % 787 Post transplant n % n % n % n % Cardiovascular disease + cerebrovascular disorder Hypertension *Hypertension: BP systolic >4 and BP diastolic >9 or have either Beta blocker/ Calcium channel blocker / ACE inhibitor / ARBs/ Other antihypertensive Deaths and graft loss In 25, 66 transplant recipients died and 54 lost their grafts. The annual rates of transplant death and grafts lost remained static at % and 2 3 % respectively (Table 5.4.2). The main causes of death had consistently been infection and cardiovascular disease with 36% and 24% respectively in 25. The proportion of patients died from infection had remained static at 35-4%, which is a reflection that the patients were heavily immunosuppressed. The proportion of patient who died at home, which was usually presumed to be cardiovascular death remained relatively static (5%). Death due to cancers peaked in 23 contributing to 4% of all deaths. This had shown a decline to 6% in 24 and 25. Death due to liver disease slowly declined from % in 26 to around 3% in 25. Rejection remained the major cause of graft loss (Table 5.4.4). 4

15 Twelfth Report of the Natiol Transplant Registry 25 Table 5.4.2: Transplant patient death rate and graft loss, Number at risk Transplant death Transplant death rate % Graft loss Graft loss rate % Acute rejection Acute rejection rate % All losses All losses rate % *Graft loss=graft failure *All losses=death / graft loss (acute rejection happens concurrently with graft failure / death) Figure 5.4.2(a): Transplant recipient death rate, Death rate % Annual death rate Figure 5.4.2(b): Transplant recipient graft loss rate, Graft loss rate % Annual graft loss rate Table 5.4.3: Causes of death in transplant recipients, Cardiovascular Died at home Infection Graft failure Cancer Liver disease Accidental death 2 Others Unknown Total Cardiovascular Died at home Infection Graft failure Cancer Liver disease Accidental death Others Unknown Total

16 Twelfth Report of the Natiol Transplant Registry 25 Table 5.4.4: Causes of graft failure, Rejection Calcineurin toxicity Other drug toxicity 3 2 Ureteric obstruction Infection Vascular causes Recurrent/ de novo rel disease Chronic allograft nephropathy / IFTA Technical problem Others Unknown Total Rejection Calcineurin toxicity Other drug toxicity Ureteric obstruction 2 Infection Vascular causes Recurrent/ de novo rel disease Chronic allograft nephropathy / IFTA Technical problem 2 Others Unknown Total

17 Twelfth Report of the Natiol Transplant Registry PATIENT AND GRAFT SURVIVAL 5.5. Patient survival Overall patient survival rates from 26 to 25 were 96%, 94%, 9% and 75% at year, 3, 5 and respectively. Factors affecting patient survival were years of transplantation, age at transplantation, primary disease and type of transplantation. Patients who underwent rel transplantation in later years (between 2 to 25) have lower risk of mortality in comparison to those who were transplanted between This may reflect better recipient selection and preparation as well as improvement in magement in the post transplant period. Older patients were also at higher risk of mortality. Table 5.5.(a): Patient survival, Figure 5.5.(a): Patient survival, N % Survival SE Interval (years) *n=number at risk SE=standard error Cumulative survival Transplant patient survival, Duration in years Table 5.5.(b): Risk factors for transplant patient survival Factors of transplant (ref*) n 49 Hazard Ratio Age at transplant < (ref*) >=55 Gender Male (ref*) 549. Female Primary diagnosis Unknown primary (ref*) 8. Diabetes mellitus GN/SLE Polycystic kidney Obstructive nephropathy Others Type of transplant Commercial cadaver (ref*) 2. Commercial live donor Living donor Cadaver HBsAg Negative (ref*) 863. Positive Anti-HCV Negative (ref*) 863. Positive 7 95% CI (.73,.952) (.67, 3.272) (.466, 5.823) (.474,.442) (.4, 2.86) (.342,.67) (.89, 5.449) (.95, 9.3) (.828, 3.73) (.433, 2.43) (.377,.569) (.78, 4.82) P value

18 Twelfth Report of the Natiol Transplant Registry Graft survival Overall graft survival rates were 92%, 88%, 82% and 62% at year, 3, 5 and respectively. (Table and Figure 5.5.a & 5.5.2a). Table 5.5.2(a): Graft survival, Interval % n (years) Survival SE *n=number at risk SE=standard error Figure 5.5.2(a): Graft survival, Cumulative survival Transplant graft survival, Duration in years Table 5.5.2(b): Risk factors for transplant graft survival Factors of transplant (ref*) n 49 Hazard Ratio Age at transplant < (ref*) >=55 Gender Male (ref*) 549. Female 34. Primary diagnosis Unknown primary (ref*) 8. Diabetes mellitus 6.72 GN/SLE Polycystic kidney Obstructive nephropathy Others Type of transplant Commercial cadaver (ref*) 2. Commercial live donor 25.6 Living donor 36.3 Cadaver HBsAg Negative (ref*) 863. Positive Anti-HCV Negative (ref*) 863. Positive 95% CI (.556,.579) (.83,.749) (.223, 2.428) (.677,.48) (.239, 2.2) (.658,.967) (.65, 3.654) (.76, 5.494) (.98, 3.36) (.582, 2.4) (.624,.7) (.36, 3.638) P value

19 Twelfth Report of the Natiol Transplant Registry Patient survival according to type of transplant Outcomes of rel transplantation over the last years in 4 different donor groups are shown in Table and Figures For local living rel transplantation, the, 3 and 5-year patient survival was 98%, 96% and 95% respectively. The patient survival of commercial cadaveric transplantation was 96%, 93%, 89% and 75% at year, 3, 5 and respectively. The patient survival of local cadaveric allograft recipients was worse in comparison to all other groups. This may be due to older age group, longer dialysis vintage and more comorbidity in this group. The patient survival of commercial live donor transplant is comparable to that of local live donor transplant. Table 5.5.3: Udjusted patient survival by type of transplant, Type of Commercial Commercial Transplant Cadaver Live Donor Live Donor Cadaver Interval (years) n % Survival S % S S n SE n % Survival n % Survival E Survival E E *n=number at risk SE=standard error Figure 5.5.3: Patient survival by type of transplant, Transplant patient survival by Type of Transplant, Live donor Figure 5.5.4: Graft survival by type of transplants, Transplant graft survival by Type of Transplant, Commercial live donor Commercial cadaver.8 Commercial live donor Cumulative survival.6.4 Cadaver Cumulative survival.6.4 Commercial cadaver Live donor Cadaver Duration in years Duration in years 9

20 Twelfth Report of the Natiol Transplant Registry Graft survival according to type of transplant For local living rel transplantation, the graft survival was 94%, 92% and 87% at year, 3 and 5 respectively. The graft survival for commercial cadaveric transplant was 94%, 9%, 85% and 68% at year, 3, 5 and respectively. This is comparable to graft survival of local living transplantation. The graft survival of local cadaveric allograft recipients was worse in comparison to all other groups with only 69% and 33% graft surviving at 5 and years respectively. Table 5.5.4: Graft survival by type of transplant, Type of Commercial Commercial Transplant Cadaver Live Donor Live Donor Cadaver Interval (years) n % Survival SE n % Survival SE n % Survival SE n % Survival SE *n=number at risk SE=standard error Outcome of living related rel transplantation Patient and graft survival for living related transplants were compared between two cohorts, those transplanted between 26-2 and In living related transplants, patient survival appears to be better in those transplanted in the latter period. However, graft survival between these 2 cohorts was similar (Table and Figure 5.5.5a & b). Table 5.5.5(a): Patient survival by year of transplant (Living related transplant, 26-25) of Transplant Interval (years) n % Survival SE n % Survival SE *n=number at risk SE=standard error 2

21 Twelfth Report of the Natiol Transplant Registry 25 Figure 5.5.5(a): Patient survival by year of transplant (Living related transplant, 26-25). Transplant patient survival by of Transplant, Figure 5.5.5(b): Graft survival by year of transplant (Living related transplant, 26-25). Transplant graft survival by of Transplant, Cumulative survival.6.4 Cumulative survival Duration in years Duration in years Table 5.5.5(b): Graft survival by year of transplant (Living related transplant, 26-25) of Transplant Interval (years) n % Survival SE n % Survival SE *n=number at risk SE=standard error Outcome of commercial cadaveric transplantation Patient and graft survival for commercial cadaveric transplants were compared between two cohorts, those transplanted between 26-2 and Patient survival appeared to be better for the later cohort However, graft survival between these 2 cohorts was similar (Table & Figure 5.5.6(a) & (b)). Table 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 26-25) of Transplant Interval (years) n % Survival SE n % Survival SE *n=number at risk SE=standard error 2

22 Twelfth Report of the Natiol Transplant Registry 25 Figure 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 26-25). Transplant patient survival by of Transplant, Figure 5.5.6(b): Graft survival by year of transplant (Commercial cadaver transplant, 26-25). Transplant graft survival by of Transplant, Cumulative survival Cumulative survival Duration in years Duration in years Table 5.5.6(b): Graft survival by year of transplant (commercial cadaver transplant, 26-25) of Transplant Interval (years) n % Survival SE n % Survival SE *n=number at risk SE=standard error 22

23 Twelfth Report of the Natiol Transplant Registry CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS 5.6. Risk factors for ischaemic heart disease (IHD) In 25, 86.8% of patients were hypertensive, 2.4% were diabetic and 48.% had rel insufficiency fulfilling CKD III and above. Thirty-seven percent of patients had 2 cardiovascular risk factors while 2.8% had all 3 major risk factors. The proportion of patients with hypertension appeared to be decreasing over the years. The proportion of patients with diabetes remained the same. Table 5.6.: Risk factors for IHD in rel transplant recipients at year Diabetes 25 (.5) 26 (.6) 33 (2.) 27 (.6) 24 (.5) Hypertension** 69 (4.7) 594 (37.) 637 (38.5) 655 (39.9) 66 (4.3) C KD 32 (7.8) 67 (.4) 49 (9.) 23 (7.5) 47 (9.) Diabetes + Hypertension** 96 (5.7) 98 (6.) 96 (5.8) (6.8) 6 (7.) Diabetes + CKD 44 (2.6) 4 (2.6) 4 (2.4) 36 (2.2) 46 (2.8) CKD + Hypertension** 482 (28.4) 465 (29.) 52 (3.4) 483 (29.4) 436 (26.6) Diabetes + CKD + Hypertension** 226 (3.3) 2 (3.) 96 (.9) 26 (2.6) 29 (2.8) **Hypertension: BP systolic > 4 and BP diastolic > 9 OR have either Beta blocker / Calcium channel blocker / ACE inhibitor / AIIRB / Other antihypertensive drugs GFR (ml/min/.73m2) =.2*(4-age(year ))*weight(kg) / creatinine (µmol/l) if male GFR (ml/min/.73m2) =.85*(.2*(4-age(year)) *weight(kg) / creatinine (µmol/l) if female CKD stage III-GFR, 3-6 CKD stage IV-GFR, 5-3 CKD stage V-GFR, <5 Figure 5.6.(a): Venn diagram for pre and post transplant complications (in %) at year 2 Figure 5.6.(b): Venn diagram for pre and post transplant complications (in %) at year 22 23

24 Twelfth Report of the Natiol Transplant Registry 25 Figure 5.6.(c): Venn diagram for pre and post transplant complications (in %) at year 23 Figure 5.6.(d): Venn diagram for pre and post transplant complications (in %) at year 24 Figure 5.6.(e): Venn diagram for pre and post transplant complications (in %) at year 25 24

25 Twelfth Report of the Natiol Transplant Registry Blood Pressure classification according to JNC VI criteria, 2-25 In 25, twenty-four percent of rel transplant recipients had stage I systolic hypertension and 4% had stage II hypertension despite being on treatment (Table (a)). Ten percent of patients had stage I diastolic hypertension. Table 5.6.2(a): Systolic BP, < >= Figure 5.6.2(a): Systolic BP, 2-25 Percent Systolic BP <2 Systolic BP 2-29 Systolic BP 3-39 Systolic BP 4-59 Systolic BP 6-79 Systolic BP >= Table 5.6.2(b): Diastolic BP, < >= Figure 5.6.2(b): Diastolic BP, 2-25 Percent Diastolic BP <8 Diastolic BP 8-85 Diastolic BP Diastolic BP 9-99 Diastolic BP -9 Diastolic BP >=

26 Twelfth Report of the Natiol Transplant Registry Level of allograft function Table and Figure summarises the CKD Stage classification. In 25, 4% of rel transplant recipients had CKD Stage III, whilst another 8% had CKD Stage IV. CKD Stage V (impending rel replacement therapy) was found in 2% of rel transplant recipients. Table 5.6.3: CKD stages, Stage Stage Stage Stage Stage Figure 5.6.3: CKD stages by year Percent CKD Stage CKD Stage 2 CKD Stage 3 CKD Stage 4 CKD Stage Body mass index In 25, 56% percent of rel transplant recipients had BMI of 25 or below. However, 29% were overweight and another 4% were obese. Table 5.6.4: BMI, < > Figure 5.6.4: BMI, 2-25 Percent BMI <2 BMI 2-25 BMI 25-3 BMI > LDL cholesterol LDL cholesterol had been identified as the primary lipid target for prevention of corory heart disease by Natiol Cholesterol Education Program (NCEP) with a log linear relationship between risk of corory heart disease and level of LDL cholesterol. In 25, 44% of our rel transplant recipients had LDL levels below 2.6 mmol/l. It is encouraging to observe the LDL level in transplant patients continue to improve in the last five years. Whether or not this translated into less cardiovascular mortality in the transplant population is still questioble. Proportion of patients with serum LDL >3.4 mmol/l remained relatively static throughout the last five-year period. In terms of other cholesterol parameters, 55% had total cholesterol levels <5. mmol/l and 8% had HDL cholesterol levels <. mmol/l. 26

27 Twelfth Report of the Natiol Transplant Registry 25 Table 5.6.5(a):LDL, < >= Figure 5.6.5(a): LDL, 2-25 Percent LDL <2.6 LDL LDL >= Table 5.6.5(b):Total cholesterol, < > Figure 5.6.5(b): Total cholesterol, 2-25 Percent Total Cholesterol <4. Total Cholesterol Total Cholesterol Total Cholesterol Total Cholesterol > Table 5.6.5(c): HDL, < > Figure 5.6.5(c): HDL, 2-25 HDL < HDL -.3 HDL >.3 8 Percent

28 Twelfth Report of the Natiol Transplant Registry Blood pressure control There was no change in the percentage of patients who were on antihypertensives over the last five-year period with 7 to 76% were on antihypertensive medications. Furthermore, the percentage of patients taking multiple antihypertensive medications had not changed much with 38% taking one antihypertensive, 26% taking two anti-hypertensives and 7% taking 3 antihypertensives. The systolic blood pressure appears to be increasing over the last 5 years, whereas diastolic BP had remained relatively the same. In 25, 4% of patients still had systolic BP of >6 mmhg and % had diastolic BP of > 9 mmhg despite being given antihypertensive(s). Table 5.6.6(a): Treatment for hypertension, 2-25 n % on antihypertensives drug antihypertensives antihypertensives % on antihypertensive % on 2 % on Table 5.6.6(b): Distribution of systolic BP without antihypertensives, 2-25 n Mean SD Median LQ UQ % Patients 6mmHg Table 5.6.6(c): Distribution of diastolic BP without antihypertensives, 2-25 n Mean SD Median LQ UQ % patients 9mmHg Table 5.6.6(d): Distribution of systolic BP on antihypertensives, 2-25 n Mean SD Median LQ UQ % Patients 6mmHg Table 5.6.6(e): Distribution of diastolic BP on antihypertensives, 2-25 n Mean SD Median LQ UQ % Patients 9 mmhg

29 Twelfth Report of the Natiol Transplant Registry QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS Eight hundred sixty three patients who were transplanted from were alysed for QoL index score. They reported median QoL index score of (Table & Figure 5.7.). There was no difference in the median QoL index score between diabetics and non-diabetics who underwent rel transplantation during this period (Table & Figure 5.7.2). There was also no difference seen between gender (Table & Figure 5.7.3) and age (Table & Figure 5.7.4). It is worthwhile to note that those above 6 years old also enjoyed the same QoL index score () as their younger counterparts (Table & Figure 5.7.4). This trend of high QoL index score remained the same for the last ten years. Table 5.7.: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients Dialysis modality QoL score Number of patients 863 Centile (LQ).5 (median).75 (UQ).9.95 Table 5.7.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients Diabetes mellitus No Yes Number of patients 76 3 Centile (LQ).5 (median).75 (UQ).9.95 Figure 5.7.: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients Cumulative distribution of QOL by Modality, Transplant Patients Figure 5.7.2: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients Cumulative distribution of QOL by DM, Transplant Patients Cumulative Distribution QL-Index Score Cumulative Distribution QL-Index Score No Yes 29

30 Twelfth Report of the Natiol Transplant Registry 25 Table 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients Gender Male Female Number of patients Centile (LQ).5 (median).75 (UQ).9.95 Figure 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients Cumulative Distribution Cumulative distribution of QOL by Gender, Transplant Patients QL-Index Score Male Female Table 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients Age group (years) < >=6 Number of patients Centile (LQ) -.5 (median) -.75 (UQ) Figure 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients Figure 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients Cumulative distribution of QoL-Index by Age Group, Transplant patients Cumulative distribution of QOL by of Entry, Transplant Patients Cumulative Distribution QL-Index Score Age <2 Age 2-39 Age 4-59 Age >=6 Cumulative Distribution QL-Index Score

31 Twelfth Report of the Natiol Transplant Registry 25 Table 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients of Entry Number of patients Centile (LQ).5 (median).75 (UQ)

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