title: Risk of death following kidney allograft failure: a systematic review and meta-analysis of cohort studies.
abstract: BACKGROUND
  People with kidney allograft failure represent an increasing fraction of all those starting dialysis therapy. We sought to summarize prognosis following kidney allograft failure and identify potentially beneficial interventions or modifiable risk factors.
  
  
  METHODS
  We searched MEDLINE and EMBASE (inception to 1 October 2013) and article reference lists without language restriction and selected cohort studies of all-cause mortality and fatal infection-related and cardiovascular events in people starting dialysis following kidney allograft failure. Two reviewers independently extracted data on study design, participant characteristics, dialysis modality, transplant nephrectomy, immunosuppression strategy, transplant-naive comparators and risk of bias. Discrepancies were resolved with a third reviewer.
  
  
  RESULTS
  Forty studies comprising 249 716 participants met the inclusion criteria. The first year of dialysis therapy was associated with the highest mortality. By random effects meta-analysis, annual risk of death, from years 1 to 4, was 0.12 [95% confidence interval (95% CI): 0.09-0.15], 0.06 (95% CI: 0.05-0.07), 0.05 (95% CI: 0.04-0.06) and 0.05 (95% CI: 0.04-0.06), respectively. We found high heterogeneity in each meta-analysis, which remained unexplained by prespecified subgroup analyses. We could not find sufficient information to summarize the risk for fatal infection-related and cardiovascular events, or to test the role of transplant nephrectomy or different immunosuppressive strategies. Risk of bias was high, especially participation bias.
  
  
  CONCLUSIONS
  Mortality is higher during the first year of dialysis treatment following kidney allograft failure than in subsequent years. Insufficient data are available to assess factors or interventions potentially impacting prognosis following kidney allograft failure. In a culture promoting transplantation, clinical research of different models of care in this growing high-risk population should be a research priority.
authors.affiliation: Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Rameez
authors.initials: R
authors.lastname: Kabani
authors.affiliation: Department of Medicine, University of Calgary, Calgary, AB, Canada Community Health Sciences, Institute of Public Health, University of Calgary, Calgary, AB, Canada Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
authors.forename: Robert R
authors.initials: RR
authors.lastname: Quinn
authors.affiliation: Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.
authors.forename: Suetonia
authors.initials: S
authors.lastname: Palmer
authors.affiliation: Community Health Sciences, Institute of Public Health, University of Calgary, Calgary, AB, Canada Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
authors.forename: Adriane M
authors.initials: AM
authors.lastname: Lewin
authors.affiliation: Department of Surgery, University of Calgary, Calgary, AB, Canada.
authors.forename: Serdar
authors.initials: S
authors.lastname: Yilmaz
authors.affiliation: Department of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Tibbles
authors.affiliation: Community Health Sciences, Institute of Public Health, University of Calgary, Calgary, AB, Canada Institute of Health Economics, University of Alberta, Edmonton, AB, Canada.
authors.forename: Diane L
authors.initials: DL
authors.lastname: Lorenzetti
authors.affiliation: Cochrane Renal Group, Sydney, Australia School of Public Health, University of Sydney, Sydney, Australia Mario Negri Sud Consortium, Saunta Maria Imbaro, Chieti, Italy Diaverum Medical Scientific Office, Lund, Sweden University of Bari, Bari, Italy.
authors.forename: Giovanni F M
authors.initials: GF
authors.lastname: Strippoli
authors.affiliation: Department of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Kevin
authors.initials: K
authors.lastname: McLaughlin
authors.affiliation: Department of Medicine, University of Calgary, Calgary, AB, Canada Community Health Sciences, Institute of Public Health, University of Calgary, Calgary, AB, Canada Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
authors.forename: Pietro
authors.initials: P
authors.lastname: Ravani
mesh_terms: D000328:Adult; D064591:Allografts; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016030:Kidney Transplantation; D008297:Male; D009392:Nephrectomy; D011379:Prognosis; D006435:Renal Dialysis
chemical_list: D007166:Immunosuppressive Agents
keywords: end-stage kidney failure; kidney allograft (transplant) failure; transplant nephrectomy