Isabel Fonseca1,2,3, Laetitia Teixeira3,4, Jorge Malheiro1,2, La Salete Martins1,2, Leonídio Dias1, António Castro Henriques1,2, Denisa Mendonça3,4. 1. Department of Nephrology and Kidney Transplantation, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal. 2. Unit for Multidisciplinary Investigation in Biomedicine (UMIB), Porto, Portugal. 3. EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal. 4. Department of Population Studies, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.
Abstract
OBJECTIVE: In kidney transplantation, the impact of delayed graft function (DGF) on long-term graft and patient survival is controversial. We examined the impact of DGF on graft and recipient survival by accounting for the possibility that death with graft function may act as a competing risk for allograft failure. STUDY DESIGN AND SETTING: We used data from 1281 adult primary deceased-donor kidney recipients whose allografts functioned at least 1 year. RESULTS: The probability of graft loss occurrence is overestimated using the complement of Kaplan-Meier estimates (1-KM). Both the cause-specific Cox proportional hazard regression model (standard Cox) and the subdistribution hazard regression model proposed by Fine and Gray showed that DGF was associated with shorter time to graft failure (csHR = 2.0, P = 0.002; sHR = 1.57, P = 0.009), independent of acute rejection (AR) and after adjusting for traditional factors associated with graft failure. Regarding patient survival, DGF was a predictor of patient death using the cause-specific Cox model (csHR = 1.57, P = 0.029) but not using the subdistribution model. CONCLUSIONS: The probability of graft loss from competing end points should not be reported with the 1-KM. Application of a regression model for subdistribution hazard showed that, independent of AR, DGF has a detrimental effect on long-term graft survival, but not on patient survival.
OBJECTIVE: In kidney transplantation, the impact of delayed graft function (DGF) on long-term graft and patient survival is controversial. We examined the impact of DGF on graft and recipient survival by accounting for the possibility that death with graft function may act as a competing risk for allograft failure. STUDY DESIGN AND SETTING: We used data from 1281 adult primary deceased-donor kidney recipients whose allografts functioned at least 1 year. RESULTS: The probability of graft loss occurrence is overestimated using the complement of Kaplan-Meier estimates (1-KM). Both the cause-specific Cox proportional hazard regression model (standard Cox) and the subdistribution hazard regression model proposed by Fine and Gray showed that DGF was associated with shorter time to graft failure (csHR = 2.0, P = 0.002; sHR = 1.57, P = 0.009), independent of acute rejection (AR) and after adjusting for traditional factors associated with graft failure. Regarding patient survival, DGF was a predictor of patientdeath using the cause-specific Cox model (csHR = 1.57, P = 0.029) but not using the subdistribution model. CONCLUSIONS: The probability of graft loss from competing end points should not be reported with the 1-KM. Application of a regression model for subdistribution hazard showed that, independent of AR, DGF has a detrimental effect on long-term graft survival, but not on patient survival.
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