Access to kidney transplantation and re-transplantation from childhood to adulthood: long-term data from the ERA Registry

Abstract

Kidney transplantation; Paediatric; Re-transplantation

Trasplantament renal; Pediatria; Retrasplantament

Trasplante renal; Pediatría; Retrasplante

Background and hypothesis Knowledge regarding access to first kidney transplantation (KT) and subsequent KT in patients commencing kidney replacement therapy (KRT) in childhood is limited. Methods Using European Renal Association (ERA) Registry data, we investigated European patients who started KRT below 20 years of age between 1978 and 2019. Access and determinants to first, second, and third KT were assessed using multivariable Cox regression. Results Totals of 12 623, 4077, and 1186 patients were included while awaiting first, second, and third KT, at median ages of 13.8 (IQR: 7.5–17.4), 20.9 (IQR: 16.5–26.1), and 26.6 (IQR: 20.3–32.8) years, respectively. During the study period, overall access was 87.8%, 72.7%, and 60.5% for first, second, and third KT, respectively, and median time to each KT was 0.9 (IQR: 0.2–2.1), 1.9 (0.6–4.5), and 2.6 (IQR: 1.0–5.3) years. Younger age at KRT initiation (aHR 0-4 vs. 10–14 years: 0.54; 95%CI: 0.51–0.57) and female sex (HR: 0.94; 95%CI: 0.90–0.98) were associated with lower access to first KT. KT candidates between 15 and 19 years had lower access to first and second KT (aHR: 0.69; 95%CI: 0.66–0.73, and aHR: 0.70; 95%CI: 0.61–0.81) compared to 10–14 year-olds. Compared to CAKUT, glomerulonephritis patients had lower access to KT (aHR: 0.75; 95%CI: 0.71–0.80 for first, aHR: 0.89; 95%CI: 0.81–0.98 for second, and aHR: 0.80; 95%CI: 0.66–0.97 for third KT). Similarly, patients with primary renal diseases with high risk of recurrence, had lower chances of receiving a first and second KT (aHR: 0.80; 95%CI: 0.76–0.85 for first, aHR: 0.86; 95%CI: 0.78–0.95 for second KT). Access to re-transplantation was also higher with previous pre-emptive KT and previous graft survival exceeding 5 years. Conclusion Our study highlights KT access disparities particularly for females, the youngest recipients, high-risk age (15–19 years), and diseases with recurrence risk. Notably, pre-emptive transplants and enduring previous grafts offer advantages regarding re-transplantation.

The ERA Registry is funded by the European Renal Association (ERA). S.D.M. reports to be the Director or NIHR Great Ormond Street Hospital Clinical Research Facility. A.P.J.d.V. reports receiv- ing consulting fees from Hansa, Sanofi, Takeda, Neovii, Astellas, Sandoz; is a member of the Steering Committee Renal Lifecycle Trial; being past chair of the Dutch Kidney Transplant Advisory Committee and board member of the Dutch Nephrology Associ- ation Board member Nefrovisie. S.S.S. reports receiving consult- ing fees from Novo Nordisk and support from Amicus Therapeu- tics for attending meetings/and or travel; and is board member of Nordic Kidney Group and Scandiatransplant. T.J. reports receiv- ing grants from Lastentautien tutkimussäätiö (Foundation for Pe- diatric Research); support for attending meetings/and or travel from Helsinki and Uusimaa Heath District; and being a board member of the Scandiatransplant council. M.S. reports receiving consulting fees from Hansa Biopharma and Vfor Pharma; and payment for lectures from Otsuka. M.A. reports receiving grants from Slovenian Research and Innovation Agency; payments for lectures from Astellas Pharma, Chiesi, Astra Zeneca, Takeda, No- vartis, Bayer, and Boehringer Ingelheim; and support for attend- ing meetings/and or travel from Chiesi. L.A.P. reports receiving grants from Kidney Research UK, Academy of Medical Sciences and National Institute for Health and Care Research; support for attending meetings through a paid role at UK Kidney Associa- tion/UK Renal Registry; and being a UK Renal Registry Paediatric Research Lead. S.M. reports being the Chair of Scottish Renal Reg- istry, Public Health Scotland. R.P. reports support for the present manuscript from Landspitali University Hospital and University of Iceland; and receiving grants from The University of Iceland Re- search Fund Research and Landspitali University Hospital Science Fund; being the President of the Icelandic Society of Transplan- tation and a board member of the Icelandic Society of Internal Medicine. A.O. reports receiving grants from Sanofi and is Director of the Catedra Mundipharma-UAM of diabetic kidney disease and the Catedra Astrazeneca-UAM of chronic kidney disease and elec- trolytes; consultancy or speaker fees or travel support from Ad- viccene, Alexion, Astellas, Astrazeneca, Amicus, Amgen, Bioporto, Boehringer Ingelheim, Fresenius Medical Care, GSK, Bayer, Sanofi- Genzyme, Sobi, Menarini, Mundipharma, Kyowa Kirin, Lilly, Free- line, Idorsia, Chiesi, Otsuka, Novo-Nordisk, Sysmex and Vifor Fre- senius Medical Care Renal Pharma and Spafarma; is a board mem- ber of ERA Council and SOMANE; and has stock options in Telara Pharma. V.S.S. reports having support for the present manuscript from European Renal Association. J.H. reports receiving consult- ing fees from Alnylam pharmaceuticals; is a board member of DSMB RCT Obirins (obinutuzumab vs rituximab in nephrotic syn- drome) and ESPN Council. K.J.J. reports having support for the present manuscript from European Renal Association; and receiv- ing a grant from the European Society for Paediatric Nephrology. All other co-authors declare that they have no relevant financial interests.