title: Poor long-term outcome in second kidney transplantation: a delayed event.
abstract: BACKGROUND
  Old studies reported a worse outcome for second transplant recipient (STR) than for first transplant recipient (FTR) mainly due to non-comparable populations with numbers confounding factors. More recent analysis, based on improved methodology by using multivariate regressions, challenged this generally accepted idea: the poor prognosis for STR is still under debate.
  
  
  METHODS
  To assess the long-term patient-and-graft survival of STR compared to FTR, we performed an observational study based on the French DIVAT prospective cohort between 1996 and 2010 (N = 3103 including 641 STR). All patients were treated with a CNI, an mTOR inhibitor or belatacept in addition to steroids and mycophenolate mofetil for maintenance therapy. Patient-and-graft survival and acute rejection episode (ARE) were analyzed using Cox models adjusted for all potential confounding factors such as pre-transplant anti-HLA immunization.
  
  
  RESULTS
  We showed that STR have a higher risk of graft failure than FTR (HR = 2.18, p = 0.0013) but that this excess risk was observed after few years of transplantation. There was no significant difference between STR and FTR in the occurrence of either overall ARE (HR = 1.01, p = 0.9675) or steroid-resistant ARE (HR = 1.27, p = 0.4087).
  
  
  CONCLUSIONS
  The risk of graft failure following second transplantation remained consistently higher than that observed in first transplantation after adjusting for confounding factors. The rarely performed time-dependent statistical modeling may explain the heterogeneous conclusions of the literature concerning second transplantation outcomes. In clinical practice, physicians should not consider STR and FTR equally.
authors.affiliation: Institut de Transplantation Urologie Néphrologie, Inserm U, CHU Hôtel Dieu, Nantes, France.
authors.forename: Katy
authors.initials: K
authors.lastname: Trébern-Launay
authors.forename: Yohann
authors.initials: Y
authors.lastname: Foucher
authors.forename: Magali
authors.initials: M
authors.lastname: Giral
authors.forename: Christophe
authors.initials: C
authors.lastname: Legendre
authors.forename: Henri
authors.initials: H
authors.lastname: Kreis
authors.forename: Michèle
authors.initials: M
authors.lastname: Kessler
authors.forename: Marc
authors.initials: M
authors.lastname: Ladrière
authors.forename: Nassim
authors.initials: N
authors.lastname: Kamar
authors.forename: Lionel
authors.initials: L
authors.lastname: Rostaing
authors.forename: Valérie
authors.initials: V
authors.lastname: Garrigue
authors.forename: Georges
authors.initials: G
authors.lastname: Mourad
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Morelon
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Soulillou
authors.forename: Jacques
authors.initials: J
authors.lastname: Dantal
mesh_terms: D015331:Cohort Studies; D005602:France / Q000453:epidemiology; D006084:Graft Rejection / Q000453:epidemiology*; D006085:Graft Survival / Q000502:physiology*; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000401:mortality; D016016:Proportional Hazards Models; D012086:Reoperation; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome