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Optimizing Waiting Duration for Renal Transplants in the Setting of Renal Malignancy: Is Two Years Too Long to Wait?
Kevin A. Nguyen, MS1, Jamil S. Syed, MD1, Randy Luciano, MD, PhD1, Brian Shuch, MD1, Srinivas Vourganti, MD2.
1Yale School of Medicine, New Haven, CT, USA, 2Rush University Medical Center, Chicago, IL, USA.
BACKGROUND: For potential renal transplant recipients, waiting duration is a significant, modifiable risk factor affecting survival. For patients with end-stage renal disease (ESRD) also affected by cancer, a waiting period is commonly imposed prior to transplant. However, no evidence based universal recommendations currently exist to guide clinicians. We aim to improve decision making by evaluating the impact of waiting duration on cancer-specific mortality (CSM), non-cancer-specific mortality (NCSM), and overall survival (OS) in kidney cancer patients awaiting renal transplant.
METHODS: The United States Renal Data System (USRDS) was used to identify patients with a known cause of ESRD from the period 1983 to 2007. Evaluation of OS was performed with Kaplan-Meier estimates and Cox Proportional Hazards models. Fine-Gray competing risk models were used to assess CSM and NCSM.
RESULTS: Of 1,374,175 patients with known causes of ESRD, 228,984 (16.7%) received a transplant. Transplant recipients with renal malignancy associated ESRD (RM-ESRD) had longer waiting durations than those with other known causes of ESRD (2.4 vs. 1.3 years, p<0.0001). RM-ESRD patients who had shorter waiting durations (0-2 years) had better overall survival than those who waited longer (2+ years) (10-year OS 69.0% vs. 46.7% respectively, p<0.0001); with similar CSM (10-year CSM of 10.3% vs. 10.2% respectively, p<0.883), while NCSM was worse for those with longer waiting durations (10-year NCSM of 20.7% vs. 44.3% respectively, p<0.0001). RM-ESRD with shorter wait time to transplantation had similar OS to other causes of ESRD, while those who waited longer had worse OS due to worse NCSM (see figure). On Cox modeling, the status of RM-ESRD was not a significant predictor (p=0.07), while longer waiting duration remained significant (p<0.0001).
CONCLUSIONS: We found that longer waiting durations were associated with worse outcomes for patients with RM-ESRD. We found that CSM was not affected by waiting duration, while NCSM significantly improved with shorter wait time. These findings suggest that the overall survival of potential transplant recipients with RM-ESRD may be improved by reducing waiting duration. Further prospective trials evaluating this are warranted.
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