CHAPTER 5 RENAL TRANSPLANTATION. Editor: Dr Rosnawati Yahya

CHAPTER 5 Editor: Dr Rosnawati Yahya Expert Panels: Dr Rosnawati Yahya Dr Ng Kok Peng Dr Suryati Binti Yakaob Dr Mohd Zaimi Abd Wahab Dr Yee Seow Ying Dr Wong Hin Seng Contents 5. Stock and Flow of Renal Transplantation Stock and Flow Transplant Rates 5. 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 Renal Transplant Recipients 5.7 QoL Index Score in Renal Transplant Recipients

List of Tables Table 5..: Stock and flow of renal transplantation, 7-6... 4 Table 5..: New transplant rate per million population (pmp), 7-6... 4 Table 5..3: Transplant prevalence rate per million population (pmp), 7-6... 5 Table 5..4: Place of transplantation, 7-6... 6 Table 5..: Renal transplant recipients characteristics, 7-6... 7 Table 5..: Primary causes of end stage renal failure, 7-6... 7 Table 5.3.: Type of renal transplantation, 7-6... 8 Table 5.3.: Biochemical data, -6... 9 Table 5.3.3: Immunosuppressive Medications, -6... Table 5.3.4: Non immunosuppressive medications, -6... Table 5.4.: Post transplant complications, -6... Table 5.4.: Transplant patient death rate and graft loss, 7-6... 3 Table 5.4.3: Causes of death in transplant recipients, 7-6... 3 Table 5.4.4: Causes of graft failure, 7-6... 4 Table 5.5.(a): Patient survival, 7-6... 5 Table 5.5.(b): Risk factors for transplant recipient mortality 7-6... 5 Table 5.5.(a): Graft survival, 7-6... 6 Table 5.5.(b): Risk factors for transplant graft loss 7-6... 6 Table 5.5.3: Unadjusted patient survival by type of transplant, 7-6... 7 Table 5.5.4: Graft survival by type of transplant, 7-6... 8 Table 5.5.5(a): Patient survival by year of transplant (Living related transplant, 7-6)... 8 Table 5.5.5(b): Graft survival by year of transplant (Living related transplant, 7-6)... 9 Table 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 7-6)... 9 Table 5.5.6(b): Graft survival by year of transplant (commercial cadaver transplant, 7-6)... Table 5.6.: Risk factors for IHD in renal transplant recipients at year -6... Table 5.6.(a): Systolic BP, -6... Table 5.6.(b): Diastolic BP, -6... Table 5.6.3(a): Treatment for hypertension, -6... Table 5.6.3(b): Distribution of systolic BP without antihypertensives, -6... 3 Table 5.6.3(c): Distribution of diastolic BP without antihypertensives, -6... 3 Table 5.6.3(d): Distribution of systolic BP on antihypertensives, -6... 3 Table 5.6.3(e): Distribution of diastolic BP on antihypertensives, -6... 3 Table 5.6.4: CKD stages, -6... 3 Table 5.6.5: BMI, -6... 4 Table 5.6.6(a): LDL, -6... 4 Table 5.6.6(b): Total cholesterol, -6... 4 Table 5.6.6(c): HDL, -6... 5 Table 5.7.: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 7-6... 5 Table 5.7.: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 7-6... 5 Table 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 7-6... 6

List of Tables (cont.) Table 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 7-6... 6 Table 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 7-6... 7 List of Figures Figure 5..: Stock and flow of renal transplantation, 7-6... 4 Figure 5..: New transplant rate, 7-6... 5 Figure 5..3: Transplant prevalence rate, 7-6... 5 Figure 5..4(a): Places of transplantation, 7-6... 5 Figure 5..4(b): Place of transplantation within Malaysia... 6 Figure 5.4.(a): Transplant recipient death rate, 7-6... 3 Figure 5.4.(b): Transplant recipient graft loss rate, 7-6... 3 Figure 5.5.(a): Patient survival, 7-6... 5 Figure 5.5.(a): Graft survival, 7-6... 6 Figure 5.5.3: Patient survival by type of transplant, 7-6... 7 Figure 5.5.4: Graft survival by type of transplants, 7-6... 7 Figure 5.5.5(a): Patient survival by year of transplant (Living related transplant, 7-6)...9 Figure 5.5.5(b): Graft survival by year of transplant (Living related transplant, 7-6)... 9 Figure 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 7-6)... Figure 5.5.6(b): Graft survival by year of transplant (Commercial cadaver transplant, 7-6)... 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 3... Figure 5.6.(c): Venn diagram for pre and post transplant complications (in %) at year 4... Figure 5.6.(d): Venn diagram for pre and post transplant complications (in %) at year 5... Figure 5.6.(e): Venn diagram for pre and post transplant complications (in %) at year 6... Figure 5.6.(a): Systolic BP, -6... Figure 5.6.(b): Diastolic BP, -6... Figure 5.6.4: CKD stages by year... 3 Figure 5.6.5: BMI, -6... 4 Figure 5.6.6(a): LDL, -6... 4 Figure 5.6.6(b): Total cholesterol, -6... 4 Figure 5.6.6(c): HDL, -6... 5 Figure 5.7.: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 7-6... 5 Figure 5.7.: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 7-6... 5 Figure 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 7-6... 6 Figure 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 7-6... 6 Figure 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 7-6... 6 3

5. STOCK AND FLOW The number of new transplant patients decreased from 3 in 7 to its lowest in 6 with only 8 transplant surgeries performed in 6. This substantial reduction in the number of new transplants was predominantly due to reduction in the number of transplantation performed in Kuala Lumpur and Selayang Hospital which have been the main transplant centres in Malaysia. The number of transplant performed in China has remained relatively static. However, the was an increase in the number of transplant performed in other overseas countries. It is disturbing to observe that the number of new transplants decreased by 4% with only 48 transplant performed in 6. The number of functioning renal transplants had increased by 8% from 795 in 7 to 9 in and declined steadily from onwards with 84 functioning renal transplant in 6 (Table 5..). Despite advances in immunosuppression, the rate of allograft failure remained the same with -3% of allograft loss every year. Table 5..: Stock and flow of renal transplantation, 7-6 7 8 9 3 4 5 6 New transplant patients 3 3 4 8 3 7 99 9 8 8 Died 46 59 49 48 55 64 57 65 67 49 Graft failure 38 39 37 45 4 46 49 45 55 54 Lost to Follow up 8 5 5 7 9 5 Functioning graft at 3 st December 795 87 86 89 9 98 894 866 847 84 Figure 5..: Stock and flow of renal transplantation, 7-6 New patients Functioning graft at 3st Dec,,8,6 No. of patients,4,, 8 6 4 7 8 9 3 4 5 6 The incidence rate of renal transplantation had remained static in the last ten years which is between 3 to 5 per million population (Table & Figure 5..). This is extremely low in comparison to Australia and New Zealand, which reported 37 and 7 per million population in. Table 5..: New transplant rate per million population (pmp), 7-6 7 8 9 3 4 5 6 New transplant patients 3 3 4 8 3 7 99 9 8 8 New transplant rate, pmp 4 5 5 4 4 4 3 3 4 3 4

Table 5..3: Transplant prevalence rate per million population (pmp), 7-6 7 8 9 3 4 5 6 Functioning graft at 3 st December 795 87 86 89 9 98 894 866 847 84 Transplant prevalence rate, pmp 66 66 67 66 66 65 64 6 6 59 The transplant prevalence rate continue to drop over the last years at 66 per million population in 7 to 59 per million population in 6 (Table & Figure 5..3). Figure 5..: New transplant rate, 7-6 8 Rate, pmp Figure 5..3: Transplant prevalence rate, 7-6 7 Rate, pmp New Transplant rate, pmp 7 6 5 4 3 Transplant Prevalence rate, pmp 6 5 4 3 7 8 9 3 4 5 6 7 8 9 3 4 5 6 Transplantation in local centers increased with 5 transplants performed in 6, increasing to 86 transplants in. Unfortunately, this increase was not sustained and the number of renal transplants performed in local centers had remained static in and 3, and subsequently decline to its lowest level at 48 transplants performed in 6. This is disturbing 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 was encouraging to see that the number of transplants performed in China continued to drop from 65 cases (49.6%) in 8 down to cases (. %) in 3. Unfortunately, the figure rose to 6 cases (4.8%) in 6. It is worrying to see the number of transplants performed in other overseas centres continue to increase with cases reported in 6 (Table 5..4 and Figure 5..4 (a)). The number of transplants performed in Hospital Kuala Lumpur dropped significantly from 39 transplants in 5 to only 8 transplant in 6. Similar trend was seen in Selayang Hospital from 6 transplants performed in 5 to only 9 transplants erformed in 6 The number of transplants performed in University Malaya Medical Centre is showing an encouraging improvement with 8 tranplants in to 7 transplants in 6 (Table 5..4 and Figure 5..4 (b)). Figure 5..4(a): Places of transplantation, 7-6 Local Other overseas China Unknown India Number 6 4 8 6 4 7 8 9 3 4 5 6 5

Figure 5..4(b): Place of transplantation within Malaysia HKL PPUKM Prince Court UMMC Selayang Hospital Other local 4 3 7 8 9 3 4 5 6 Table 5..4: Place of transplantation, 7-6 7 8 9 HKL 36 3.9 3 4.4 36 5.5 7. 37 8.5 PPUKM.8 5 3.8 3..6.8 Prince Court Medical Centre 4.8 7 5.5 3 UMMC 5 4.4 7.6 7. 7.8 8 6. Selayang Hospital 4.4 7.6 8.8 9 4.8 6 Other local.8 3.3 3..8 China 45 39.8 65 49.6 6 44 53 4.4 4 3.8 India 4 3.5 3.3.4.6 Other overseas 5 4.4 3.3 3. 8 6.3 4 3. Unknown Total 3 3 4 8 3 3 4 5 6 HKL 36 33.6 36 36.4 36 39.6 39 36. 8 PPUKM 3.8 Prince Court Medical Centre 5 4 6 6. 4 4.9 UMMC 9.3 3 3. 3 4.3 6 4.8 7.7 Selayang Hospital 6 5 7 7. 6 4. 9 Other local.9 China.6. 5 6.5 6 4.8 3 5.9 India.9. Other overseas.9 5 5. 6 6.6. 5.6 Unknown Total 7 99 9 8 8 6

5. RECIPIENTS CHARACTERISTICS Over the last years, the mean age of recipients at the time of transplantation increased steadily from 37 years to 44 years. More male patients underwent renal transplantation yearly (Table 5..). For the past ten years, the proportion of diabetic patients who underwent renal transplantation decreased slowly from 8% in 6 and only % in 5, however there was a rebound in the number of diabetic patients who went for transplant in 6. Patients with hepatitis B had decreased from 7% earlier to -6% yearly in the last 3 years. The overall number of patients with hepatitis C who went for renal transplantation remained low which ranged from % to 9% yearly. In terms of underlying cause of end stage renal failure (Table 5..), the commonest cause was glomerulonephritis (GN), hypertension followed by diabetes. The proportion of transplant recipients having end stage renal disease due to unknown causes had decreased from 44% in 6 to 5% in 6. Table 5..: Renal transplant recipients characteristics, 7-6 7 8 9 3 4 5 6 New Transplant Patients 3 3 4 8 3 7 99 9 8 8 Age at transplant (years), Mean 37 37 38 4 38 37 35 39 4 44 Age at transplant (years), SD 6 4 4 4 5 3 3 3 3 4 % Male 64 6 64 66 7 6 6 55 58 66 % Diabetic (co-morbid/ primary renal disease) 4 8 8 9 4 8 3 4 % HBsAg positive 7 3 4 3 3 4 6 % Anti-HCV positive 9 3 7 3 3 3 4 5 Table 5..: Primary causes of end stage renal failure, 7-6 7 8 9 New transplant patients 3 3 4 8 3 Glomerulonephritis 38 34 4 3 55 39 49 38 35 7 Diabetes Mellitus 3 5 6 8 6 9 5 Hypertension 38 34 3 4 4 8 46 36 46 35 Obstructive uropathy 6 5 6 5 6 4 7 5 7 5 ADPKD 3 3 8 6 5 4 3 Drugs/ toxic nephropathy Hereditary nephritis Unknown 46 4 6 46 44 3 38 3 55 4 Others 6 5 5 4 5 4 3 4 5 6 New transplant patients 7 99 9 8 8 Glomerulonephritis 37 35 4 4 3 35 48 44 34 4 Diabetes Mellitus 7 6 3 3 9 5 8 Hypertension 9 7 7 7 6 9 38 35 38 46 Obstructive uropathy 4 4 3 3 5 5 ADPKD 4 4 3 3 Drugs/ toxic nephropathy Hereditary nephritis 3 3 Unknown 3 8 9 9 3 9 5 Others 3 3 8 9 3 4 7

5.3 TRANSPLANT PRACTICES 5.3. Type of renal transplantation The proportion of commercial transplantation had reduced in time from 44. % in 7 to 39 % in 6. This was predominantly due to the marked decline in commercial cadaveric transplantation (39.8% in 7 to 4 % in 3). However, since 4, the percentage of commercial cadaveric transplantation has slowly increased to.% in 6. There number of commercial living transplantation fluctuated from 4.4 % in 7, peaked at 6.6 % in gradually decline then but slowly increase and peaked at 6.8 % in 6. Local cadaveric transplantation made up % of transplants (9 recipients) in 6, which was the lowest ever seen in the last ten years. Local living donor transplantation had shown an initial rise from 36 transplants in 7, peaked at 63 transplants (67.3%) in 3. Unfortunately, this rise was not sustained and the number of local living donor transplants dropped to 35 (3.3%) recipients in 4 and 3 (7.4%) in 5. In 6, there was a rise in number of local living donor transplants, 4 recipients (5% out of all renal transplantations). The year 7 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 which peaked in 3 with 86.9% of the total transplantation performed locally. However, then onwards proportion declined slowly with 79.% in 4, 75% in 5 and 6% in 6. The declined in numbers were mainly due to lower number of renal transplant operations in 4-5 for various technical reasons. Table 5.3.: Type of renal transplantation, 7-6 7 8 9 Commercial cadaver 45 39.8 6 47.3 38 7. 7. 7.7 Commercial live donor 5 4.4 3.3 6 8.4 34 6.6 3 4.6 Live donor (genetically related) 9.5 36 7.5 7 9. 5 9.5 3 4.6 Live donor (emotionally related) 4.4 6 4.6 5.6 3. 6.3 Cadaver 7 3.9 4 8.3 35 4.8 34 6.6 4 3.8 Total 3. 3. 4 99.9 8. 3. 3 4 5 6 Commercial cadaver 7 6.5 4 4. 7 7.7.. Commercial live donor 8 6.8 9 9. 3. 6 4.8 6.8 Live donor (genetically related) 37 34.6 48 48.5 4 6.4.4 7 3.9 Live donor (emotionally related) 6 5. 5 5. 9 9.9 8 7.4 4 7. Cadaver 9 7. 3 3. 39 4.9 5 47. 9. Total 7. 99. 9. 8. 8. *Commercial Cadaver (China, India, other oversea) *Commercial live donor (living unrelated) *Cadaver (local) 8

5.3. Biochemical data Table 5.3. summarised the biochemical data for all the transplant recipients from to 6. Table 5.3.: Biochemical data, -6 Biochemical parameter Summary 3 4 5 6 Creatinine, umol/l n 688 698 695 83 87 Mean 3.5 3. 8. 9.7 6.7 SD 69.3 76.6 6.8 79.7 74.4 Median 6 5 5 Minimum 36 9 Maximum 9 898 657 88 97 Hb, g/dl n 688 698 695 83 87 Mean.8.8.6.6.6 SD.9.9.8.9.8 Median.8.7.7.7.7 Minimum 4.4 6. 5.3 5. 4.5 Maximum 8.7 8.6 8.5 8.5 8.9 Albumin, g/l n 688 698 695 83 87 Mean 4.3 39.9 39.6 39. 39.7 SD 4.5 4.6 4.8 4.6 4.3 Median 4 4 4 4 4 Minimum 9 9 Maximum 57 54 56 64 5 Calcium, mmol/l n 688 698 695 83 87 Mean.3.3.3.3.3 SD..... Median.3.3.3.3.3 Minimum.4.... Maximum 3. 3.5 3.3 3. 4. Phosphate, mmol/l n 688 698 695 83 87 Mean..... SD.3.3..3. Median..... Minimum.5.5.5.5.5 Maximum 3.9 3..8 3. 3. Alkaline phosphate (ALP), U/L n 688 698 695 83 87 Mean 79.6 79. 8. 8.7 8.4 SD 39.8 46.5 45.3 58.6 4.9 Median 7.5 7. 73. 73. 73. Minimum Maximum 58 985 73 964 65 ALT, U/L n 688 698 695 83 87 Mean 9.6 9.9 9.7 6.9 6.4 SD 5.7 37.8 3.5 5.. Median 3 3 4 Minimum 4 4 4 4 4 Maximum 356 88 88 4 37 Total cholesterol, mmol/l n 688 698 695 83 87 Mean 5. 5.4 5. 5. 5. SD..9.5.5. Median 5. 5. 5. 5. 5. Minimum.7..7.3. Maximum.4 58. 46. 49. 4.9 LDL cholesterol, mmol/l n 688 698 695 83 87 Mean.9.8.8.8.9 SD.8.8..9.8 Median.8.8.8.8.8 Minimum..9.9.9. 9

Table 5.3.: Biochemical data, -6 (cont ) Biochemical parameter Summary 3 4 5 6 Maximum 8.9 7.7.8.4. HDL cholesterol, mmol/l n 688 698 695 83 87 Mean.5.6.5.5.5 SD.4.5.5.5.5 Median.5.5.5.5.5 Minimum.4.5.4.4.5 Maximum 7.5 7.5 6.9 6.8 9. Systolic blood pressure, mmhg n 688 698 695 83 87 Mean 3.6 9.4 3. 9.7 3. SD 5.7 5.3 4.7 4.8 5.4 Median 3 3 3 3 3 Minimum 8 8 65 7 7 Maximum 45 9 Diastolic blood pressure, mmhg n 688 698 695 83 87 Mean 78.8 77.5 78. 77.5 77.6 SD 9.3 8.9 8.7 9. 9. Median 8. 78. 79. 78. 8. Minimum 3 4 4 3 3 Maximum 6 4 4 5.3.3 Immunosuppression medications Majority of patients were on combination immunosuppression with very small numbers on single immunosuppression drugs either prednisolone predominantly, followed by calcineurin inhibitors, antiproliferative agents and proliferation signal inhibitor (PSI). Calcineurin-inhibitor based therapy remained the mainstay immunosuppressive therapy with 86% of patients receiving it in 6. Cyclosporin was the most widely used calcineurin inhibitors until 3. However, there was a gradual decline in cyclosporine usage with 5% in to 36% in 6 which coincided with the increasing use of tacrolimus, of which 39% in to 45% in 4 and 5% in 6. The usage of anti-proliferative agents had shown similar trend over the last 5 years. The used of azathioprine continue to decline from 5% in to % in 5 and remain static in 6. The use of mycophenolic acid fluctuated between 6 to 68% from to 6. (Figure 5.3.3) The use of proliferation signal inhibitor (PSI) has increased slowly in time from 6% in to 9% in 6. Table 5.3.3: Immunosuppressive Medications, -6 Medication data All (i) Immunosuppressive drug(s) treatment Prednisolone Cyclosporin A Single drug treatment 3 4 5 6 933 9 96 87 88 8 8 8 37 6 7 3 7 6 Tacrolimus (FK56) 3 4 7 6 Azathioprine MPA 4 4 3 6 PSI 4 4 Others

Combined drug treatment Medication data 3 4 5 6 All 88 933 9 96 87 (i) Immunosuppressive drug(s) treatment Prednisolone 786 95 86 94 86 95 786 94 73 95 Cyclosporin A 95 5 898 46 837 44 78 4 664 36 Tacrolimus (FK56) 75 39 8 4 86 45 97 48 95 5 Azathioprine 9 5 3 7 66 4 38 6 MPA 3 64 94 67 3 68 5 66 6 6 PSI 7 6 6 6 43 8 65 9 Others 5.3.4 Non immunosuppression medications In terms of non-immunosuppressive medications, calcium channel blockers are the most commonly used antihypertensive as a single or combination agent contributing to 65% of usage. This is followed by beta blockers with 4% of patients on it either alone or in combination with other medications in 6. The use of ACE inhibitors or angiotensin receptor blocker or both showed % increment over the last 5 years; 35% of patients were on ACE inhibitors or angiotensin II receptor blockers (AIIRB) or both in and this has increased to 4 % in 4 and 45% in 6. The usage of alpha blockers either as single drug or in combination has been consistently low as there may be an associated risk of heart failure with usage of the drug. Despite CAD related death is high amongst recipients, the usage of anti-lipid remains very low. Table 5.3.4: Non immunosuppressive medications, -6 Single drug treatment Medication data 3 4 5 6 All 88 933 9 96 87 Non Immunosuppressive drug(s) treatment Alpha blocker 4 8 9 5 Beta blocker 93 66 9 66 9 68 9 Calcium channel blocker 338 8 33 6 345 8 39 7 39 8 ACE inhibitor 9 5 5 5 98 5 7 4 8 4 ARBs 65 3 9 5 69 4 89 5 5 6 Anti-lipid 3 Other antihypertensive 9 6 4 Combined drug treatment Medication data 3 4 5 6 All 88 933 9 96 87 Non Immunosuppressive drug(s) treatment Alpha blocker 6 5 8 6 8 38 7 35 7 Beta blocker 69 33 659 34 646 34 6 33 64 33 Calcium channel blocker 835 44 85 44 94 49 9 47 866 47 ACE inhibitor 78 5 34 8 39 7 9 5 34 8 ARBs 3 8 4 6 4 35 6 36 7 Anti-lipid 3 5 3 Other antihypertensive 3 6 6

5.4 TRANSPLANT OUTCOMES 5.4. Post transplant complications Hypertension remained as the most common comorbidity seen in the kidney transplant recipients pre and post-transplantation with 53% and 33% respectively. Only % of the patients had diabetes pre-transplant. 6% either developed diabetes post operatively or had existing diabetes as a comorbid after the transplant. Future data should focus on the development of NODAT and try to explain the discrepancy between the drop in proportion of patients with diabetes pre and post-operatively. In terms of cardiovascular and cerebrovascular disease, 3% had either or both prior to transplant and another % developed these complications post transplanted. This should raise concerns with regards to the detection of cardiovascular diseases as the proportion diagnosed were small given that cardiovascular event was the third most common cause of death in our transplant recipients. Cancer remains uncommon both before and after transplantation. Table 5.4.: Post transplant complications, -6 All patients Diabetes (either as primary renal disease or comorbid) Cancer Pre transplant 3 4 5 6 784 845 83 79 75 5 4 53 4 43 3 3 3 8 Cardiovascular disease + cerebrovascular disorder 54 3 5 3 46 3 45 3 48 3 Hypertension 4 56 34 56 99 54 955 53 9 53 All patients Diabetes (either as primary renal disease or comorbid) Cancer n % 784 Post transplant 3 4 5 n % n % n % 845 83 79 6 n % 75 5 6 5 5 7 45 8 99 6 5 8 9 Cardiovascular disease + cerebrovascular disorder 6 3 4 3 4 Hypertension 49 8 538 9 58 3 557 3 58 33 *Hypertension: BP systolic >4 and BP diastolic >9 or have either Beta blocker/ Calcium channel blocker / ACE inhibitor / ARBs/ Other antihypertensive 5.4. Deaths and graft loss In 6, 49 transplant recipients died and 54 lost their grafts. The annual rates of transplant death dropped to.7% while grafts lost remained static at 3% (Table 5.4.). The main cause of death in 6 was unknown in 9% of the transplant recipients. This was followed by infection with 8% and cardiovascular with 6% respectively. The proportion of patients who died from infection showed an improvement but the proportions of unknown causes were much higher in 6 compared to 5. Establishing the cause of death will be important to devise a better management plan for our patients. The proportion of patient who died at home, which was usually presumed to be cardiovascular related was 7%. Death due to cancers in 6 contributed to % of all deaths (Table 5.4.3).

Majority of the graft losses had an unknown cause with 43%. Rejection was second with 4% followed by chronic allograft nephropathy/ifta with 3% (Table 5.4.4). Determining the cause of graft loss is of utmost importance to better understand the reasons for graft failure in our population. Therefore, the need to diagnose them appropriately should be attempted whenever possible. Table 5.4.: Transplant patient death rate and graft loss, 7-6 7 8 9 3 4 5 6 Number at risk 794 85 839 876 96 94 9 879 856 86 Transplant death 46 59 49 48 55 64 57 65 67 49 Transplant death rate %.6 3.3.7.6.9 3.3 3 3.5 3.6.7 Graft loss 38 39 37 45 4 46 49 45 55 54 Graft loss rate %...4..4.6.4 3 3 Acute rejection 4 4 3 8 53 Acute rejection rate %.8.3.7 4.3.8 All losses 84 98 86 93 95 6 3 All losses rate % 4.7 5.4 4.7 5 5 5.7 5.6 5.9 6.6 5.7 *Graft loss=graft failure *All losses=death / graft loss (acute rejection happens concurrently with graft failure / death) Figure 5.4.(a): Transplant recipient death rate, 7-6 Death rate % 4 3.5 3.5.5.5 Annual death rate Graft loss rate % Figure 5.4.(b): Transplant recipient graft loss rate, 7-6 3.5.5.5 Annual graft loss rate 7 8 9 3 4 5 6 7 8 9 3 4 5 6 Table 5.4.3: Causes of death in transplant recipients, 7-6 7 8 9 Cardiovascular 4 3 8 Died at home 4 9 7 8 6 7 5 4 7 Infection 8 39 9 3 9 39 8 38 38 Graft failure Cancer 4 9 9 5 6 6 3 5 9 Liver disease 4 4 4 Accidental death Others 3 5 6 Unknown 5 33 3 9 8 5 4 5 Total 46 59 49 48 55 3

Table 5.4.3: Causes of death in transplant recipients, 7-6 (cont ) 3 4 5 6 Cardiovascular 9 8 3 5 Died at home 5 8 6 4 6 4 6 4 8 Infection 8 44 39 6 4 4 36 3 7 Graft failure 4 3 Cancer 7 8 4 4 6 5 7 5 Liver disease 4 6 3 5 3 Accidental death 4 Others 3 Unknown 4 9 7 6 3 4 9 Total 64 57 65 67 49 Table 5.4.4: Causes of graft failure, 7-6 7 8 9 Rejection 3 6 56 54 8 4 4 35 Calcineurin toxicity 3 3 Other drug toxicity 3 Ureteric obstruction Infection 5 Vascular causes 3 4 3 4 3 Recurrent/ de novo renal disease 3 Chronic allograft nephropathy / IFTA Technical problem Others 5 5 4 4 Unknown 9 8 5 4 47 55 Total 38 39 37 45 4 3 4 5 6 Rejection 48 7 55 3 67 38 3 4 Calcineurin toxicity 4 9 3 6 4 4 7 Other drug toxicity Ureteric obstruction Infection 4 5 9 Vascular causes 4 3 5 4 7 Recurrent/ de novo renal disease 3 6 4 3 5 3 6 Chronic allograft nephropathy / IFTA 3 7 8 5 7 3 Technical problem Others 3 6 4 3 5 4 Unknown 43 6 33 8 8 36 3 43 Total 46 49 45 55 54 5.5 PATIENT AND GRAFT SURVIVAL 5.5. Patient survival Patient survival rates from 7 6 were 96% at year, 9% at year-5 and 7% at year- post transplantation. Risk factors affecting patient survival were primary diagnosis and type of transplant. Patients with deceased donor renal transplantation had higher risk of mortality compared to living renal transplant. 4

Table 5.5.(a): Patient survival, 7-6 Interval % n (years) Survival SE 3 955 96 837 95 3 745 94 4 63 9 5 56 9 6 4 88 7 9 86 8 8 83 9 84 8 5 7 *n=number at risk SE=standard error Figure 5.5.(a): Patient survival, 7-6 Cumulative survival Transplant patient survival, 7-6..8.6.4.. 3 4 5 6 7 8 9 Duration in years Table 5.5.(b): Risk factors for transplant recipient mortality 7-6 Factors of transplant 7- (ref*) n 479 Hazard Ratio. -6 354.544 Age at transplant -39 (ref*) 37. 4-54 >=55 Gender 49 34.44.55 Male (ref*) 57. Female 36.983 Primary diagnosis Unknown primary (ref*) 77. Diabetes mellitus 53.83 GN/SLE 34.68 Polycystic kidney 3.367 Obstructive nephropathy 6.38 Others 3.857 Type of transplant Commercial cadaver (ref*) 7. Commercial live donor 46.478 Living donor 3.4 Cadaver (Deceased donor) 93.58 HBsAg Negative (ref*) 833. Positive NA Anti-HCV Negative (ref*) 833. Positive NA 95% CI (.946,.59) (.983,.3) (.59, 4.65) (.675,.43) (.95,.83) (.676,.6) (.49,.763) (.849, 6.36) (.3, 3.5) (.87,.674) (.677,.9) (.54, 4.84) NA NA P value.8.6.37.97.667.578.33..4.97.6. NA NA 5.5. Graft survival Graft loss rates reported below was not censored for death. Graft survival rates were 9% at year-, 8% at year-5 and 57% at year- post transplantation. Older age and patients with cadaver renal transplantation had higher risk of graft loss. 5

Table 5.5.(a): Graft survival, 7-6 Interval % n (years) Survival SE 3 955 9 837 9 3 745 88 4 63 85 5 56 8 6 4 79 7 9 74 8 8 69 9 84 65 5 57 8 *n=number at risk SE=standard error Figure 5.5.(a): Graft survival, 7-6 Cumulative survival..8.6.4.. Transplant graft survival, 7-6 3 4 5 6 7 8 9 Duration in years Table 5.5.(b): Risk factors for transplant graft loss 7-6 Factors of transplant 7- (ref*) n 479 Hazard Ratio. -6 354.68 Age at transplant -39 (ref*) 37. 4-54 49 3.93 >=55 34 4.694 Gender Male (ref*) 57. Female 36.5 Primary diagnosis Unknown primary (ref*) 77. Diabetes mellitus 53.988 GN/SLE 34.85 Polycystic kidney 3.683 Obstructive nephropathy 6 4.6 Others 3.8 Type of transplant Commercial cadaver (ref*) 7. Commercial live donor 46.7 Living donor 3.558 Cadaver 93.365 HBsAg Negative (ref*) 833. 95% CI (.39,.496) (.663, 6.3) (.5, 4.47) (.585,.78) (.98, 3.77) (.36,.879) (.86, 5.45) (.6, 5.) (.9, 3.56) (.49,.336) (.56,.8) (.4, 4.54) P value.337 <..7 Positive NA NA NA Anti-HCV Negative (ref*) 833. Positive NA NA NA.984.984.648.78.4.9.864.43.9 6

5.5.3 Patient survival according to type of transplant Outcomes of renal transplantation by type of transplant are shown in Table 5.5.3, Figures 5.5.3 and 5.5.4. Patient survival of cadaveric renal transplant was worse in comparison to live donor transplant. The patient survival of local living renal transplant was 98% and 96% at year- and year-5 respectively. In comparison, the patients who had commercial live donor renal transplant had slightly poorer survival beyond year-5 post transplant. Overall, patient survival of local cadaveric transplant is worst among all type of transplant, likely due to older age, longer dialysis vintage and more comorbidity. Table 5.5.3: Unadjusted patient survival by type of transplant, 7-6 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 6 77 46 3 93 95 49 99 357 98 56 9 78 94 3 98 35 97 3 89 3 68 93 7 97 9 97 68 88 4 57 89 5 95 7 96 4 86 5 49 88 9 93 74 96 85 6 33 84 59 9 8 96 8 83 7 8 7 86 95 53 8 8 8 78 8 86 6 9 3 74 9 33 75 5 86 9 9 8 7 3 75 43 9 3 *n=number at risk SE=standard error Figure 5.5.3: Patient survival by type of transplant, 7-6. Transplant patient survival by Type of Transplant, 7-6 Live donor Figure 5.5.4: Graft survival by type of transplants, 7-6. Transplant graft survival by Type of Transplant, 7-6.8 Commercial cadaver.8 Live donor Cumulative survival.6.4 Cadaver Commercial live donor Cumulative survival.6.4 Commercial cadaver Cadaver Commercial live donor... 3 4 5 6 7 8 9 Duration in years. 3 4 5 6 7 8 9 Duration in years 7

5.5.4 Graft survival according to type of transplant The graft survival rates reported were not censored for death. Local live donor graft survival at year-, year-3 and year-5 was 94%, 9% and 86% respectively. The graft survival of commercial live donor and commercial cadaveric transplant were similar to graft survival of local living renal transplant. Local cadaveric transplant had worst graft survival; 84% at year- and 7% at year-5 post transplant. Table 5.5.4: Graft survival by type of transplant, 7-6 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 6 77 46 3 93 94 49 99 357 94 56 84 78 9 3 97 35 93 3 8 3 68 9 7 96 9 9 68 77 4 57 86 5 9 7 89 4 73 5 49 84 9 89 74 86 7 6 33 8 59 83 8 84 8 69 7 77 7 74 8 53 6 8 8 7 8 7 6 77 3 55 9 33 69 5 7 9 7 8 5 3 69 36 7 3 *n=number at risk SE=standard error 5.5.5: Outcome of living related renal transplantation Patient survival of local live donor renal transplant appeared to be better in those transplanted in -6 compared to those transplanted in 7-. However, graft survival (not censored for death) between these two cohorts was similar. Table 5.5.5(a): Patient survival by year of transplant (Living related transplant, 7-6) of Transplant 7- -6 Interval (years) n % Survival SE n % Survival SE 6 9 97 66 99 88 96 38 98 3 87 96 6 98 4 79 94 49 98 5 7 94 98 6 8 94 7 93 8 6 9 9 9 9 9 *n=number at risk SE=standard error 8

Figure 5.5.5(a): Patient survival by year of transplant (Living related transplant, 7-6). Transplant patient survival by of Transplant, 7-6 -6 Figure 5.5.5(b): Graft survival by year of transplant (Living related transplant, 7-6). Transplant graft survival by of Transplant, 7-6.8 7-.8-6 Cumulative survival.6.4 Cumulative survival.6.4 7-.... 3 4 5 6 7 8 9 Duration in years 3 4 5 6 7 8 9 Duration in years Table 5.5.5(b): Graft survival by year of transplant (Living related transplant, 7-6) of Transplant 7- -6 Interval (years) n % Survival SE n % Survival SE 6 9 94 66 94 88 93 38 94 3 87 93 6 9 4 79 9 49 9 5 7 88 8 6 8 86 7 84 8 6 78 9 9 73 73 *n=number at risk SE=standard error 5.5.6 Outcome of commercial cadaveric transplantation Patient survival and graft survival (not censored for death) of commercial cadaveric transplant appeared to be better in those transplanted in 7- compared to -6. However the small number of commercial renal transplants in the latter cohort may have skewed the result. Table 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 7-6) of Transplant 7- -6 Interval (years) n % Survival SE n % Survival SE 77 39 67 96 7 9 64 95 6 88 3 59 94 9 88 4 53 9 5 88 5 49 88 6 33 85 7 83 8 8 79 9 33 75 3 75 *n=number at risk SE=standard error 9

Figure 5.5.6(a): Patient survival by year of transplant (Commercial cadaver transplant, 7-6). Transplant patient survival by of Transplant, 7-6 Figure 5.5.6(b): Graft survival by year of transplant (Commercial cadaver transplant, 7-6). Transplant graft survival by of Transplant, 7-6 Cumulative survival.8.6.4-6 7- Cumulative survival.8.6.4-6 7-... 3 4 5 6 7 8 9 Duration in years. 3 4 5 6 7 8 9 Duration in years Table 5.5.6(b): Graft survival by year of transplant (commercial cadaver transplant, 7-6) of Transplant 7- -6 Interval (years) n % Survival SE n % Survival SE 77 39 67 95 7 89 64 94 6 85 3 59 93 9 79 4 53 88 5 63 5 49 86 6 33 8 7 79 8 8 74 9 33 7 3 7 *n=number at risk SE=standard error 5.6 CARDIOVASCULAR RISK IN RENAL TRANSPLANT RECIPIENTS 5.6. Risk factors for ischaemic heart disease (IHD) In 6, 89.5% of renal transplant recipients has hypertension,.% has diabetes and 46.9% had chronic kidney disease (CKD) stage III and above. Approximately % of renal transplant recipients had all three major risk factors for cardiovascular disease. Prevalence of hypertension appeared to be increasing in the recent 5 years but prevalence of CKD showed a decreasing trend. Table 5.6.: Risk factors for IHD in renal transplant recipients at year -6 3 4 5 6 Diabetes 7 (.7) 34 (.) 7 (.6) 4 (.5) 6 (.7) Hypertension** 594 (37.) 635 (38.4) 653 (39.8) 658 (4.) 69 (43.9) CKD 67 (.4) 48 (8.9) 3 (7.5) 47 (9.) (7.) Diabetes + Hypertension** 98 (6.) 98 (5.9) 3 (6.9) 9 (7.3) 9 (7.6) Diabetes + CKD 4 (.6) 4 (.5) 36 (.) 46 (.8) 8 (.8) CKD + Hypertension** 464 (9.) 5 (3.4) 48 (9.4) 435 (6.5) 44 (8.) Diabetes + CKD + Hypertension** (3.) 96 (.9) 7 (.6) (.8) 59 (.) **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/.73m) =.*(4-age(year ))*weight(kg) / creatinine (µmol/l) if male GFR (ml/min/.73m) =.85*(.*(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 Figure 5.6.(b): Venn diagram for pre and post transplant complications (in %) at year 3 Figure 5.6.(c): Venn diagram for pre and post transplant complications (in %) at year 4 Figure 5.6.(d): Venn diagram for pre and post transplant complications (in %) at year 5 Figure 5.6.(e): Venn diagram for pre and post transplant complications (in %) at year 6

5.6. Blood Pressure -6 Overall, blood pressure of renal transplant recipients was similar over the recent 5 years. In 6, a quarter of renal transplant recipients had systolic blood pressure of 4mmHg and % had diastolic blood pressure of 9mmHg. Table 5.6.(a): Systolic BP, -6 3 4 5 6 < 333 8 346 8 34 6 83 5 73 5-9 55 9 49 6 54 7 48 6 47 6 3-39 579 3 65 3 58 3 58 3 599 33 4-59 36 9 49 43 3 437 4 4 6-79 45 36 59 3 67 4 6 3 >=8 9 4 7 7 Percent Figure 5.6.(a): Systolic BP, -6 Systolic BP < Systolic BP -9 Systolic BP 3-39 Systolic BP 4-59 Systolic BP 6-79 Systolic BP >=8 8 6 4 3 4 5 6 Table 5.6.(b): Diastolic BP, -6 3 4 5 6 <8 68 57 84 57 57 56 993 54 99 55 8-84 493 6 473 5 46 4 468 5 449 5 85-89 69 9 8 4 3 99 9-99 35 7 8 7 44 8 63 9 54 9-9 8 6 >= 4 Figure 5.6.(b): Diastolic BP, -6 Percent Diastolic BP <8 Diastolic BP 8-85 Diastolic BP 85-89 Diastolic BP 9-99 Diastolic BP -9 Diastolic BP >= 8 6 4 3 4 5 6 5.6.3 Blood pressure control The proportion of renal transplant recipients receiving treatment for hypertension was similar over the recent 5 years. Almost three-quarter of renal transplant recipients received treatment for hypertension in 6, including 3% who required two or more antihypertensive agents. However, 5% of patients had systolic blood pressure of 6mmHg and % had diastolic blood pressure of 9mmHg despite being on treatment. Table 5.6.3(a): Treatment for hypertension, -6 n % on antihypertensives drug antihypertensives antihypertensives % on antihypertensive % on % on 3 88 7 4 4 6 3 9 7 4 6 7 4 93 74 39 9 5 5 874 7 38 6 7 6 83 74 4 6 7

Table 5.6.3(b): Distribution of systolic BP without antihypertensives, -6 n Mean SD Median LQ UQ % Patients 6mmHg 58 6. 3. 5.4 7.5 33.4 3 55 6.6 3.5 6.5 8. 35. 4 486 7.7 3. 7. 8.8 36.3 5 55 9.9 5.6 8.3 9.8 38.8 4 6 435 7.5 4.8 6.7 8. 35.7 Table 5.6.3(c): Distribution of diastolic BP without antihypertensives, -6 n Mean SD Median LQ UQ % Patients 9mmHg 58 77. 8.3 77.4 7. 8. 7 3 55 76.9 8.4 77.8 7.3 8. 6 4 486 77.9 8. 79. 7.5 83.3 7 5 55 78. 8.8 79. 7.3 83.3 6 437 78. 8.9 78. 7.3 83.3 9 Table 5.6.3(d): Distribution of systolic BP on antihypertensives, -6 n Mean SD Median LQ UQ % Patients 6mmHg 4 3.4 3.5 3.3 3.3 4. 3 3 349 3.9.5 3.5 4.7 4. 4 357 33.8 3. 3.5 5. 4.5 4 5 99 34.3 3.6 33.5 5. 4.5 4 6 9 34. 3.5 33. 5. 4.8 5 Table 5.6.3(e): Distribution of diastolic BP on antihypertensives, -6 n Mean SD Median LQ UQ % Patients 9 mmhg 44 78.4 8.5 79 73 8.6 3 349 78.4 8.3 78.8 73 83.7 8 4 357 79 8. 79 73.5 84.3 9 5 98 79 8.6 79.8 73.5 84.5 6 93 79. 8.7 8 74 84.3 5.6.4 Level of allograft function Prevalence of CKD in renal transplant recipients according to CKD stage over the last 5 years was similar. In 6, 4% had CKD stage III and % had CKD stage IV and above. Table 5.6.4: CKD stages, -6 3 4 5 6 Stage 6 7 3 3 9 Stage 74 4 74 39 73 38 78 39 699 38 Stage 3 73 39 766 4 759 4 745 4 75 4 Stage 4 35 7 49 8 49 8 45 8 39 8 Stage 5 3 3 37 4 36 Percent 8 6 4 Figure 5.6.4: CKD stages by year CKD Stage CKD Stage CKD Stage 3 CKD Stage 4 CKD Stage 5 3 4 5 6 3

5.6.5 Body mass index (BMI) BMI of renal transplant recipients in the recent 5 years remains static. In 6, 8% were overweight and 5% were obese. Table 5.6.5: BMI, -6 3 4 5 6 < 87 5 99 6 33 6 94 6 75 5-5 769 4 85 4 76 4 755 4 77 4 5-3 564 3 545 8 58 3 56 3 59 8 > 3 7 4 78 4 79 5 67 4 7 5 Percent 8 6 4 Figure 5.6.5: BMI, -6 BMI < BMI -5 BMI 5-3 BMI > 3 3 4 5 6 5.6.6 LDL cholesterol Overall, there appeared to be improvement in lipid profile in renal transplant recipients in 6 when compared to. In 6, 58% of renal transplant recipients had LDL.6mmol/L, % had total cholesterol >6.mmol/L and 9% had HDL <mmol/l. Table 5.6.6(a): LDL, -6 3 4 5 6 <.6 63 33 794 4 86 4 89 44 769 4.6-3.4 96 48 776 4 758 39 78 38 744 4 >= 3.4 353 9 357 9 349 8 35 9 35 8 Percent 8 6 4 Figure 5.6.6(a): LDL, -6 LDL <.6 LDL.6-3.4 LDL >= 3.4 3 4 5 6 Table 5.6.6(b): Total cholesterol, -6 3 4 5 6 <4. 5 3 97 5 34 6 3 7 3 8 4.-5. 645 34 659 34 75 38 74 38 66 34 5.-6. 784 4 758 39 7 36 657 35 76 38 6.- 7. 48 8 67 9 44 7 4 8 3 7 > 7. 63 3 46 49 3 54 3 5 3 Figure 5.6.6(b): Total cholesterol, -6 Percent Total Cholesterol <4. Total Cholesterol 4.-5. Total Cholesterol 5.-6. Total Cholesterol 6.-7. Total Cholesterol > 7. 8 6 4 3 4 5 6 4

Table 5.6.6(c): HDL, -6 3 4 5 6 < 3 7 46 8 53 8 57 8 57 9 -.3 447 4 534 8 55 7 484 6 484 6 >.3 3 69 47 65 55 65 37 66 97 65 Percent Figure 5.6.6(c): HDL, -6 HDL < HDL -.3 HDL >.3 8 6 4 3 4 5 6 5.7 QOL INDEX SCORE IN RENAL TRANSPLANT RECIPIENTS 833 patients who were transplanted from 7-6 were analysed for QoL index score. The overall QoL was found to be excellent with the 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 renal transplantation during this period (Table & Figure 5.7.). 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 7-6 Dialysis modality QoL score Number of patients 833 Centile.5 9..5 (LQ).5 (median).75 (UQ).9.95 Table 5.7.: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 7-6 Diabetes mellitus No Yes Number of patients 739 94 Centile.5 9 8. 9.5 (LQ).5 (median).75 (UQ).9.95 Figure 5.7.: Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients 7-6 Cumulative distribution of QOL by Modality, Transplant Patients Figure 5.7.: Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients 7-6 Cumulative distribution of QOL by DM, Transplant Patients Cumulative Distribution.8.6.4. Cumulative Distribution.8.6.4. 3 4 5 6 7 8 9 QL-Index Score 3 4 5 6 7 8 9 QL-Index Score 5 No Yes

Table 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 7-6 Gender Male Female Number of patients 57 36 Centile.5 9 8. 9.5 (LQ).5 (median).75 (UQ).9.95 Cumulative Distribution Figure 5.7.3: Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients 7-6 Cumulative distribution of QOL by Gender, Transplant Patients.8.6.4. 3 4 5 6 7 8 9 QL-Index Score Male Female Table 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 7-6 Age group (years) < -39 4-59 >=6 Number of patients 37 49 34 Centile -.5-7 8. - 9 9.5 (LQ) - 9.5 (median) -.75 (UQ) -.9 -.95 - - Figure 5.7.4: Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients 7-6 Cumulative distribution of QoL-Index by Age Group, Transplant patients Figure 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 7-6 Cumulative distribution of QOL by of Entry, Transplant Patients Cumulative Distribution.8.6.4. Cumulative Distribution.8.6.4. 3 4 5 6 7 8 9 QL-Index Score Age < Age -39 Age 4-59 Age >=6 3 4 5 6 7 8 9 QL-Index Score 7 8 9 3 4 5 6 6

Table 5.7.5: Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients 7-6 of Entry 7 8 9 3 4 5 6 Number of patients 76 94 8 3 98 8 77 7 77 48 Centile.5 8 9 9 7 8 9 8. 9 9 9 9 9.5 (LQ).5 (median).75 (UQ).9.95 7