title: Mortality after Renal Allograft Failure and Return to Dialysis.
abstract: BACKGROUND
  The outcomes of patients who fail their kidney transplant and return to dialysis (RTD) has not been investigated in a nationally representative sample. We hypothesized that variations in management of transplant chronic kidney disease stage 5 leading to kidney allograft failure (KAF) and RTD, such as access, nutrition, timing of dialysis, and anemia management predict long-term survival.
  
  
  METHODS
  We used an incident cohort of patients from the United States Renal Data System who initiated hemodialysis between January 1, 2003 and December 31, 2008, after KAF. We used Cox regression analysis for statistical associations, with mortality as the primary outcome.
  
  
  RESULTS
  We identified 5,077 RTD patients and followed them for a mean of 30.9 ± 22.6 months. Adjusting for all possible confounders at the time of RTD, the adjusted hazards ratio (AHR) for death was increased with lack of arteriovenous fistula at initiation of dialysis (AHR 1.22, 95% CI 1.02-1.46, p = 0.03), albumin <3.5 g/dL (AHR 1.33, 95% CI 1.18-1.49, p = 0.0001), and being underweight (AHR 1.30, 95% CI 1.07-1.58, p = 0.006). Hemoglobin <10 g/dL (AHR 0.96, 95% CI 0.86-1.06, p = 0.46), type of insurance, and zip code-based median household income were not associated with higher mortality. Glomerular filtration rate <10 mL/min/1.73 m2 at time of dialysis initiation (AHR 0.83, 95% CI 0.75-0.93, p = 0.001) was associated with reduction in mortality.
  
  
  CONCLUSIONS
  Excess mortality risk observed in patients starting dialysis after KAF is multifactorial, including nutritional issues and vascular access. Adequate preparation of patients with failing kidney transplants prior to resuming dialysis may improve outcomes.
authors.affiliation: Department of Medicine, SUNY Downstate School of Medicine, Brooklyn, NY, USA.
authors.forename: Amarpali
authors.initials: A
authors.lastname: Brar
authors.forename: Mariana
authors.initials: M
authors.lastname: Markell
authors.forename: Dimitre G
authors.initials: DG
authors.lastname: Stefanov
authors.forename: Edem
authors.initials: E
authors.lastname: Timpo
authors.forename: Rahul M
authors.initials: RM
authors.lastname: Jindal
authors.forename: Robert
authors.initials: R
authors.lastname: Nee
authors.forename: Nabil
authors.initials: N
authors.lastname: Sumrani
authors.forename: Devon
authors.initials: D
authors.lastname: John
authors.forename: Fasika
authors.initials: F
authors.lastname: Tedla
authors.forename: Moro O
authors.initials: MO
authors.lastname: Salifu
mesh_terms: D000328:Adult; D000368:Aged; D064591:Allografts / Q000473:pathology; D000740:Anemia / Q000188:drug therapy / Q000401:mortality; D015331:Cohort Studies; D005260:Female; D005919:Glomerular Filtration Rate; D006084:Graft Rejection; D006333:Heart Failure / Q000453:epidemiology; D006397:Hematinics / Q000627:therapeutic use; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000097:blood / Q000401:mortality* / Q000628:therapy*; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D016016:Proportional Hazards Models; D006435:Renal Dialysis; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D014184:Transplantation, Homologous / Q000009:adverse effects; D014481:United States / Q000453:epidemiology
chemical_list: D006397:Hematinics; D006454:Hemoglobins