3) deceased donors (HR, 1.54; 95% CI, 1.32 to 1.82)
4) number of HLA mismatches (HR, 1.08 per one mismatch increase; 95% CI, 1.07 to 1.09)
5) recipient age (HR, 1.17 per 10-year increase; 95% CI, 1.09 to 1.25), and
6) delayed graft function (HR, 1.89; 95% CI, 1.46 to 2.47)
Ø Pooled analyses excluded, any associations of cold ischemia time, recipient race, pre transplant body mass index, diabetes, and hypertension with 1-year graft loss.
Ø limitation of this review is that we included studies identifying risk factors using Cox regression analysis for graft loss at all-time points in follow-up.
Ø Studies varied considerably in the covariates included in their predictive models (studies included 1166 covariates in their regression models). Thus, results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model
Level 2
Naglaa Abdalla
2 years ago
This meta analysis study evaluating risk factors for 1-Year graft loss after kidney
transplantation as there is expansion of the pool of kidney donors through the use of higher-risk donors, and increased attention to donor management strategies.
The data collected from 2000 to 2017 and included 35 primary observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
They found Six factors were associated with graft loss:
-donor age.
– extended criteria donors
– deceased donors
– number of HLA mismatches
– recipient age
– delayed graft function
Pooled analyses also excluded,
with a high degree of certainty, any associations of cold ischemia time, recipient race, pre-transplant body mass index, diabetes, and hypertension with 1-year graft loss.
Implication for Guidelines
Numerous recipient and donor characteristics increase the risk of graft
loss post-kidney transplantation. All such factors, although may be associated with graft loss beyond chance, may not be clinically important to diminish the magnitude of benefit
attained from transplantation.
Nazik Mahmoud
2 years ago
Meta analysis,level 2 evidence
it contain 32 study to get the risk factors of one year graft loss, it divided to donor,operation and recipient risk factors
donor in form of age and sex, operation long cold ischemia time and HLA match
recipient factors includes positive DSA,hypertension and diabetes
Rehab Fahmy
2 years ago
35 studies from many countries from 2000-2017 to assess risk factors for graft loss over one-year post-transplantation
findings:
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches,and recipient age. We identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease. With high cer- tainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Level of evidence:II as metanalysis
Hamdy Hegazy
2 years ago
Please summarize this article This article reviewed 35 studies from many countries from 2000-2017 to assess risk factors for graft loss over one-year post-transplantation. It is a large-scale review using GRADE methodology to report how certain is the evidence. Donor factors affecting graft loss: donor’s age, donor type (deceased vs living), extended criteria donors were associated with higher graft loss, donor gender, donor’s BMI. Transplant process factors affecting graft loss: HLA mismatches. Recipient factors affecting graft loss: recipient’s age, numbers of years on dialysis, smoking, IHD. Post-transplant complications affecting graft loss: acute rejection and delayed graft function. Limitations of the study: 1- Inclusion of unpublished data and registry data. 2- The included studies were variable in the co-variates. 3- The nature of the included studies and recipients with many co-morbidities. 4- The study looks only for 1-year graft loss data. What is the level of evidence provided by this article? Level IIA
Ahmed Omran
2 years ago
Kidney transplantations have the highest rate of graft survival among all other organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
This review recognized five risk factors, for which there is moderate to high confirmation in the magnitude of correlation with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age. We identified an additional five variables for which, with moderate confirmation, there is an association with 1-year graft loss: donor sex, BMI, recipients duration on dialysis, history of smoking, and CAD. With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increase of cold ischemia time, recipient age, BMI, recipient diabetes, and hypertension.
Cold ischemia time was not found to be associated with 1-year graft loss.
No evidence was found regarding association between donor creatinine and 1-year graft loss.
In summary, this systematic review and meta-analysis identified 10 risk factors for which there is moderate or high certainty in their strength and extent of association.
The factors include recipient age, donor age, ECD, deceased donors, and increasing HLA mismatches.
With high certainty, it is establish that increasing cold ischemia time, recipient BMI, recipient diabetes, and hypertension do not have significant associations with 1-year graft survival.
level 2 article.
Abdullah Raoof
2 years ago
Q1- Please summarise this article.
Abstract
With expansion of the pool of kidney grafts, by using nonstandard risk dono , the 1-year graft survival rate is subject to change. This study used to determine the 1-year graft survival rates in the low-risk and high-risk kidney transplant cases.
Design, setting, participants, & measurements: Systematic Review and Meta-Analysis.
Result:
Factors associated with graft loss ( risk factors for 1-year graft loss ) :
1- donor age
2- extended criteria donors
3- , number of HLA mismatches
4- recipient age
5- delayed graft function .
data report no associations of the following with 1-year graft loss.
1) cold ischemia time,
2) recipient race,
3) pretransplant body mass index,
4) diabetes,
5) hypertension.
Conclusions
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor,
HLA mismatch, and delayed graft function all predicted1-year graft survival .The effect of each risk factor is small.
Introduction:
Graft loss results in re start dialysis, re transplantation, or death. Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year deceased graft survival.
With expansion of the pool of kidney grafts, through the use of higher risk donors, then , 1-year graft survival may change therefore useful to identify low-risk and high-risk kidney transplant cases.
Materials and Methods: Systematic Review and Meta-Analysis.
Discussion
Principal Findings
This review identified five risk factors, with moderate to high certainty association with 1-year graft loss:
1) donor age.
2) extended criteria donors.
3) deceased donors.
4) increasing number of HLA mismatches.
5) recipient age.
five additional variables , with moderate certainty, association with 1-year graft loss:
1) donor sex.
2) donorBMI.
3) recipient’s number of years on dialysis.
4) history of smoking.
5) coronary artery disease.
This study found no association of the following variables with 1-year graft loss:
1) Increasing cold ischemia time.
2) recipient age.
3) recipient BMI.
4) Recipient diabetes.
5) recipient hypertension.
Strengths and Limitations
This study is the first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after kidney transplantation.
The use of GRADE methodology enabled us to not only report on the direction and magnitude of the association for each risk factor, but also to trans parently report on the certainty of the evidence.
One limitation of this review is that we included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
By using UNOS registry , the quality of this review is dependent upon the quality of the UNOS registry data.
Conclusion:
This systematic review and meta-analysis identify ten risk factors with moderate or high certainty of association. These factors include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches. With high certainty, this study report that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival.
Q2- What is the level of evidence provided by this article?
This is a Systematic Review and Meta-Analysis study. The Level 01 .
Dalia Ali
2 years ago
After transplantation, maximizing graft longevity becomes a focus of care. Graft loss results in return to dialysis, retransplantation, or death. Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors . With expansion of the pool of kidney grafts, through the use of higher risk donors, and increased attention to donor management strategies, 1-year graft survival may change.Itis therefore useful to identifylow-risk and high-risk kidney transplant cases.
Prognostic studies can guide clinicians and patients in better understanding factors associated with a
higher risk of graft loss in the first-year post- transplantation. Although formal risk prediction models can inform prognosis, existing models in kidney transplant perform poorly: the discriminatory performance of existing models ranges from 0.54 to 0.72, either below or marginally above the minimal threshold (0.6) for acceptable performance
Discussion
Principal Findings
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age. We identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease. With high cer- tainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Strengths and Limitations
This study is the first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after kidney transplantation. By only reviewing adjusted evidence, users of our estimates can multiply the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss. Using rigorous meta-analytic methods, the review provides precise measures, compared with any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies. The use of GRADE methodology enabled us to not only report on the direction and magnitude of the association for each risk factor, but also to trans- parently report on the certainty of the evidence.
One limitation of this review is that we included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up. By doing so, we assumed that the authors of the primary studies had tested and ensured the proportional hazards assumption necessary for validity of any reported HR. The authors of the individual studies seldom reported on assessing the necessary assumptions of their regression models. As a result, our statistical analysis for the risk of bias assessment could not be fully informed by meeting the regression model assumptions.
In the context of identifying factors that increase the risk of graft loss in the year after transplant, the studies in this review have a fundamental limitation: potential candidates for transplant may be rejected because of patient factors that were not included. The reasons for not recommending transplant in such individuals may be the most powerful determinants of outcome. These may include, but not be limited to active infections and combination of older age with constellation of other comorbidities such as obesity, cardiovascular disease, malignancies, and irreversible ob- structive or restrictive pulmonary disease
that cold ischemia time was not associated with 1-year graft loss. The simplest explanation for this finding is that, indeed, there is no association. Another plausible explanation is that present day use of storage techniques such as machine perfusion and preservation solutions minimize cold ischemia damage to the kidney
Implication for Guidelines
From this review, however, it is evident that numerous recipient and donor characteristics increase the risk of graft loss postkidney transplantation. All such factors, although may be associated with graft loss beyond chance, may not be clinically important to diminish the magnitude of benefit attained from transplantation. This necessitates the need for risk prediction models to guide clinicians in selection of candidates whose risk for graft loss (disadvantaging the societal need for organ donors) may be higher than their risk of mortality on dialysis.
In conclusion, our systematic review and meta-analysis identified ten risk factors for which we have moderate or high certainty in their strength and magnitude of association. These factors include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches. With high certainty, we were able to establish that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival.
Level II
Asmaa Khudhur
2 years ago
Risk Factors for 1-Year Graft Loss After Kidney
Transplantation
Databases from 2000 to 2017 were searched to measured the association between donor, recipient,the transplant operation , early post-operative complications and 1-year death-censored graft loss.
Donor risk factors:
Donor age /increase graft failure
Donor sex ( female versus male ) / female sex increases the risk of graft failure slightly.
Type of donor ( deceased versus living )/ deceased increases graft failure.
ECD slightly increases graft failure
BMI /higher donor BMI decrease graft failure slightly.
Increase creatinine in donor has no effect on graft failure.
Recipient characteristics:
Age of recipient/ increase 1-year graft loss.
Sex of recipient has no effect on graft loss.
Race of recipient had no effect on graft loss.
BMI of recipient has little or no effect on graft failure.
Dialysis time / prolonged time increases graft failure.
Diabetes/recipient DM has no effect on graft failure.
Transplant operation risk factors:
Cold ischemia time has no effect on graft loss.
HLA mismatch/ one mismatch increase slightly graft loss.
Level of evidence II
Wael Jebur
2 years ago
Due to the increasing utilization of extended criteria kidney donors, 1 year allograft survival might be potentially changed.
This meta-analysis involved studies conducted between 200 and 2017, to verify one year allograft survival and assess interplaying factors pertinent to the censored survival. Extended criteria donors:
1)Age more than 60 year
2)
50-59 with 2 out of 3,history of cerebrovascular accident ,Hypertension and creatinine of more 1.5. Delayed graft function :was tagged as there is allograft dysfunction necessitating HD.
patients with inferior result featured characteristics related to donor, operation and post operative course of allograft function.
Number of HLA mismatchs. was observed as significant factor for 1-year death censored graft loss.On the contrary Cold ischemia time was not recognized as substantial factor influencing outcome. Recipients associated risk factors:
Pre transplant smoking, ischemic heart disease, years on dialysis and age are associated with lower 1 year death censored allograft loss. Post transplant complication:
Acute rejection and delayed graft function are featuring higher one year death censored graft loss.
Long periods of waiting in line are still a reality for many ESKD patients. One of the alternatives for the increase in donated organs was the establishment of extended criteria, but this, together with other factors, has altered 1-year graft survival. So this systematic review and meta-analysis of studies reassess risk factors to inform prognosis, and evaluate models in kidney transplant perform. Observational studies of adult (> 18 years) kidney recipients receiving were selected their first transplant, including evaluating studies the association between any risk factors and 1-year graft loss using multivariable analysis. This studied identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, recipient age. This studied identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease. Another gain from this study was that this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension
What is the level of evidence provided by this article?
The level of evidence is 01 , because is a Meta analysis
Manal Malik
2 years ago
summary ofRisk factors for 1 year graft loss after kidney transplantation:
Graft loss/patient came back to dialysis, re transplantation or death
A systematic review and metanalysis of studies assessing high risk factors for graft loss to improve the ==of potential source of discrepancy between studies. Data sources:
Med lines embase cohort control for systematic review between the years 2000-2014 Study selection:
Select studies of adult ≥18 years
Kidney recipients
Receiving the first transplant, including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis Results:
35 eligible studies, review Jneded 18 to have high risk of bias
Risk of bias in the recipient DM and delay graft function showed statistically significant affect estimate in studies at high ==low risk of bias Discussion:
The review identified five risk factors for which there is moderate to high association with 1-year graft loss risk factors include:
1. Donor age
2. Extended criteria donors
3. Deceased donors
4. Increasing marker of HLA mismatch
5. Recipient age Moderate risk factors:
1. Donor sex
2. Donor BMI
3. Recipients number of years on dialysis
4. History of smoking
5. History of coronary artery disease
Another varible moderate factors associtted with
1- Tear graft loss :
1-donor sex.
2-donor BMI.
3-recipient number of years on dialysis.
4-history of smoking.
5- history of coronary artery disease.
Study limitation
1-study identify risk factors using cox regression analysis for graft loss at all time point in follow-up.
So our statical analysis for the risk of bias assessment could not be fully informed by meeting the regression model assumption.
2-fundamental limitation potential candidate for transplant may be reject because of patient factors.
Exclusion criteria for study
Recipient sex
Race
BMI
DM
HTN
Donor creatinine
Cold ischemia time
Extended criteria donor as arisk factor for 1 year graft loss
Implication for guidelines
Need for risk prediction models to quide clinican in selection of candidates who risk for graft loss
Ten risk factor concluded in this study:
1- Recipient age.
2- Donor age.
3- Extended criteria donor.
4- Deceased donor.
5- Increasing number of HLA mismatch .
In the future development of risk prediction models, may improve discrimination such models in turn may guide the judgment clinicians need to make in the highest risk of recipient and donor.
evidence level 2
rindhabibgmail-com
2 years ago
This is a meta-analysis included 35 studies taken after reviewing 2220 articles, analysis the causes of graft failure with in first year post-transplantation. They identified five risk factors like EDC, age of donor, DCD, degree of mismatch, BMI>30, prolonged history of dialysis.
level II
Hinda Hassan
2 years ago
1. Please summarise this article
This is a meta-analysis of the factors that influence the risk of graft loss in the first year post kidney transplant. It included 35 studies chosen after reviewing 2220 articles. The significant factors associated were only 6 including the donor age, extended criteria donors, deceased donors, number of HLA mismatches, recipient age and delayed graft function. On the other hand, cold ischemia time, recipient race, prtransplant body mass index, diabetes, and hypertension are not associated with one year graft loss.
Strong points:
1- the first large-scale, systematic review of studies addressing this subject.
2- Used rigorous meta-analytic methods to provides precise measures
3- use of GRADE methodology enabled the certainty of the evidence.
Limitation:
1- It included studies which used Cox regression analysis for graft loss at all-time points in follow-up. So, the risk of bias assessment is present.
2- This analysis depended on the United Net-work for Organ Sharing(UNOS) registry studies so, the quality of this review is dependent upon the quality of the UNOS registry data.
3- The results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model or patient factors that were not included. 2. What is the level of evidence provided by this article?
Level IIA
MICHAEL Farag
2 years ago
Level II; Systematic Review and Meta-Analysis
Systematic Review and Meta-Analysis to study Risk Factors for 1-Year Graft Loss After Kidney Transplantation
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches,and recipient age.
An additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of
smoking, and coronary artery disease.
the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Huda Saadeddin
2 years ago
Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
Discussion
Principal Findings
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age. We identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease. With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
cold ischemia time was not associated with 1-year graft loss.
no evidence of an association between donor creatinine and 1-year graft loss.
In conclusion, our systematic review and meta-analysis identified ten risk factors for which we have moderate or high certainty in their strength and magnitude of association.
These factors include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches.
With high certainty, we were able to establish that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival.
level 2
Balaji Kirushnan
2 years ago
The current article describes the systematic review and metanalysis of all post transplant patients to assess the risk factors associated with graft loss.. This was a database search from 2000 to 2017….This analysis included all observational studies only.. There were no RCT included in this meta analysis…
35 eligible primary studies have been included in the analysis and few factors were found to be associated with graft loss of moderate to severe intensity….
Meta analysis of donor factors: 6 donor factors were studied and 5 were found to be associated with graft loss. They are advanced donor age, deceased donors as compared to live donors, extended criteria donors as compared to standard criteria donor, donor BMI (higher BMI associated with higher risk) and female donors (due to low nephron mass). Donor creatinine at the time of transplant did not show association with graft loss at 1 year..
Meta analysis of transplant process: Number of HLA mismatches was associated with graft loss at 1 year while the cold ischemia time did not have an association
Meta analysis of recipient factors: All the studies included 9 variables out of which 4 were associated with 1 year graft loss…Recipient’s age, pre transplant smoking, pre transplant coronary artery disease and number of years on dialysis are the positive factors, while other factors like recipient co morbid or gender with graft loss
Meta analysis of post transplant complications: The literature reviewed also identified delayed graft function and Acute rejection as post transplant risk factors associated with graft loss at 1 year..
This is the first large scale systematic review of the observational studies to assess the risk factors for graft loss at 1 year….They also used the GRADE technology to ascertain the transparency of the risk associated with the end point….the limitation of the analysis is the use of only observational studies and not RCT…
The analysis of the risk factors paves way to develop a risk prediction model tool for assessment of graft loss in the future
The level of evidence is 2A (systematic review but including only observational studies)
Yashu Saini
2 years ago
The current review is a systematic analysis and meta analysis to assess the risk factors for the graft loss within 1 year post transplantation. the database was searched from 2000 to 2017 and all the observational studies that evaluated association between donor, recipient, early post transplant operation and 1 year death censored graft loss were included.
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLAmismatch, anddelayed graft function all predicted1-year graft survival.
STRENGTHS
first large scale systematic review.
GRADE methodology enables to report on the direction and magnitude of the association for each risk factor and transparently report on the certainty of the evidence
Provided precise measures for the association of each risk factor and graft loss.
LIMITATIONS
included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
Different covariates have been included so the effect of particular risk factor may differ according to the variable included in a certain model.
Level 2 evidence
Mohammed Sobair
2 years ago
Objective :
The objective of the study was to evaluate factors purported to influence the risk of 1-
year graft loss in kidney transplant recipients.
Introduction:
In patients with ESKD, transplant improves quality of life and survival, however, because
of the high demand and limited resources. Patient wait longtime on hemodialysis.
Kidney transplant recipients have the highest rate of graft survival among all organs
transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
. With expansion of the pool of kidney grafts, with higher risk donors, and increased
attention to donor management strategies, 1-year graft survival may change. It is
therefore useful to identify low-risk and high-risk kidney transplant case.
Materials and Methods Data Sources and Searches:
A search of bibliographic databases in February of 2017. Specifically, MEDLINE,
EMBASE, Cochrane central register for controlled trials, and Cochrane database for
systematic reviews for citations between the years 2000–2017.
Study Selection and Data Extraction:
Selected observational studies of adult (18 years) kidney recipients receiving their first
transplant, including studies evaluating the association between any risk factors and 1-
year graft loss using multivariable analysis.
Results Study Selection and Characteristics:
35 studies ultimately proved eligible.
The individual studies included patients from Canada, Denmark, Germany, Ireland, Italy,
Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and Unit states.
Risk of Bias of Individual Studies:
Of the 35 eligible studies, reviewers judged 18 to have high risk of bias.
Among the included studies, the authors included an average of 11 variables.
Across the many risk factors included in this review, only the subgroup analyses for risk
of bias in recipient diabetes and delayed graft function showed statistically significant
different effect estimates in studies at high versus low risk.
Meta-Analyses of Donor Factors:
Six donor characteristics being assessed; five were independently associated with 1-
year graft loss in the original studies and proved predictive in the met analysis.
Donor type, donor quality of deceased donor, donor age, donor sex and donor body
mass index .
Meta-Analyses of Transplant Process Factors:
The number of HLA mismatches was the only risk factor, for which we observed an
association beyond chance, with 1-year death-censored graft loss.
No significant association between cold ischemia time and graft loss.
Meta-Analyses of Recipient Factors:
Nine transplant recipient variables identified.
Four of the nine were significantly associated with 1-year death-censored graft loss:
No a statistically significant association for recipient sex, race, BMI, hypertension, or
diabetes with 1-year graft loss.
Meta-Analyses of Post-Transplant Complications:
Identified delayed graft function and acute rejection as early post-transplant
complications associated with death-censored graft loss.
For both, we observed a statistically significant association with 1- year graft loss.
Discussion:
Principal Findings:
This review identified five risk factors, for which there is :
Moderate to high certainty in the magnitude of association with 1-year graft loss: donor
age, extended criteria donors, deceased donors, increasing number of HLA mismatches,
and recipient age.
With moderate certainty, there is an association with 1-year graft loss:
Donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and
coronary artery disease.
With high certainty, the findings of this study exclude any association of the following
variables with 1-year graft loss:
Increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and
recipient hypertension.
Strengths:
Meta-analytic methods, the review provides precise measures, compared with any
individual study.
Limitations:
The risk of bias assessment could not be fully informed by meeting the regression model
assumptions.
Large registries i.e. UNOS used for data collection in USA.
Potential candidates for transplant may be rejected because of patient factors that were
not included.
Implication for Guidelines:
The optimal utilization of the factors identified as risk factors, in development of future
risk prediction models, may improve discrimination and calibration.
Such models in turn may guide the judgment clinicians need to make on the highest risk
recipient and donor.
What is the level of evidence provided by this article?
Level of evidence 2a.
amiri elaf
2 years ago
#Please summarise this article # The objective:
The objective of the study was to evaluate factors purported to influence the risk of 1-year graft loss in kidney transplant recipients.
#Introduction:
*After transplantation, maximizing graft longevity becomes a focus of care. Graft loss results in return to dialysis, re-transplantation, or death.
* With expansion of the pool of kidney grafts, through the use of higher risk donors, and increased attention to donor management strategies, 1-year graft survival may change. It is therefore useful to identify low-risk and high-risk kidney transplant cases.
# Design, setting, participants, & measurements
They searched bibliographic databases from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
# Results
*They identified 35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
* Six factors were associated with graft loss, with moderate to high degree of certainty: donor age, 1.11 per 10-year increase; 95% confidence interval [95% CI], 1.04 to 1.18), extended criteria donors (HR, 1.35; 95%CI, 1.28 to 1.42), deceased donors (HR, 1.54; 95% CI, 1.32 to 1.82), number of HLA mismatches (HR, 1.08 per one mismatch increase; 95%CI, 1.07 to 1.09), recipient age (HR, 1.17 per 10-year increase; 95%CI, 1.09 to 1.25), and delayed graft function (HR, 1.89; 95% CI, 1.46 to 2.47) as risk factors for 1-year graft loss.
* Pooled analyses also excluded, with a high degree of certainty, any associations of cold ischemia time, recipient race, pretransplant body mass index, diabetes, and hypertension with 1-year graft loss.
# Strengths and Limitations
*It is the first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss PKT.
*The estimates can multiply the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss.
* Using rigorous meta-analytic methods, it provides precise measures, Vs any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies.
*The use of GRADE methodology helps to report the direction and magnitude of the association for each risk factor and transparently report on the certainty of the evidence.
*The limitation is that included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up. By doing so, that the authors of the primary studies had tested and ensured the proportional hazards assumption necessary for validity of any reported HR.
* The quality of this review is dependent upon the quality of the UNOS registry data.
*The studies have a fundamental limitation: potential candidates
for transplant may be rejected because of patient factors that were not included.
# Conclusions
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted1-year graft survival. The effect of each risk factor is small.
# What is the level of evidence provided by this article?
*Level A 2
Tahani Ashmaig
2 years ago
Risk Factors for 1-Year Graft Loss After Kidney Transplantation ________________
Introduction
▪︎Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors. With expansion of the pool of kidney grafts, 1-year graft survival may change.
Prognostic studies can guide clinicians and patients in better understanding factors associated with a higher risk of graft loss in the first-year posttransplantation. Although formal risk prediction models can inform prognosis, existing models in kidney transplant perform poorly. ▪︎The limited performance of current models may result from including risk factors useful in one cohort but not in others.
▪︎The aim of this review:
To assess the predictive power of key risk factors for kidney graft survival at 1 year post-transplant
◇ Design, setting, participants, & measurements:
▪︎ Bibliographic databases were searched from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss. ◇ Results:
▪︎35 eligible primary studies, with 20 risk factors amenable to meta-analysis were identified. ▪︎Six factors were associated with graft loss, with moderate to high degree of certainty: donor age, extended criteria donors deceased donors, number of HLA mismatches, recipient age, and delayed graft
function as risk factors for 1-year graft loss.
▪︎Pooled analyses also excluded, with a high degree of certainty, any associations of cold ischemia time, recipient race, pre-transplant body mass index, diabetes, and hypertension with 1-year graft loss. ◇ Strengths of the study:
1. The first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after renal transplantation.
2. By only reviewing adjusted evidence, users of this estimates can multiply the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss.
3. Provides precise measures, compared with any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies.
4.The use of GRADE methodology enabled the authors to not only report on the direction and magnitude of the association for each risk factor, but also to transparently report on the certainty of the evidence. Limitations
1. Included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
2.The quality of this review is dependent upon the quality of the UNOS registry data.
3. Results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model.
4. In the context of identifying factors that increase the risk of graft loss in the year after transplant, the studies in this review have a fundamental limitation: potential candidates
for transplant may be rejected because of patient factors that were not included. The reasons for not recommending
transplant in such individuals may be the most powerful
determinants of outcome. Implication for Guidelines
▪︎From this review, however, it is evident that numerous recipient and donor characteristics increase the risk of graft
loss postkidney transplantation. All such factors, although
may be associated with graft loss beyond chance, may not be clinically important to diminish the magnitude of benefit
attained from transplantation. This necessitates the need
for risk prediction models to guide clinicians in selection of candidates whose risk for graft loss may be higher than their risk of mortality on dialysis.
▪︎Risk associations generated from this
review may inspire or provide the foundational information necessary for development of a risk prediction model. Conclusion:
▪︎This systematic review and meta-analysis
identified ten risk factors with moderate or high
certainty in their strength and magnitude of association. These
factors include recipient age, donor age, extended criteriadonors, deceased donors, and increasing number of HLA mismatches.
▪︎With high certainty, it was established
that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large
associations with 1-year graft survival.
Theepa Mariamutu
2 years ago
The paper evaluated 35 studies from various countries to assess influence of published risk factors over 1-year graft loss in KTR. However the paper included unpublished data from clinical experts.
Donor Factors:
Donor age and donor type (deceased vs living)-high certainty association with graft loss
Donor quality (extended criteria), donor female gender and donor lower BMI -moderate certainty association with graft loss.
Donor serum creatinine did not have any association with graft loss.
Transplant factors:
Number of HLA mismatch – high certainty
cold ischemia time- no effect
Recipient factors:
Recipient age – associated with high certainty
pre-transplant number of years on dialysis, smoking and coronary artery disease -moderate certainty
Recipient gender, race, BMI, hypertension, and diabetes – no effect
Post-transplant risk factors
AR and DGF – moderate certainty.
A year graft loss post kidney transplant depends on donor age, donor type, donor quality, HLA mismatch, recipient age, delayed graft function as well as donor BMI and gender, and recipient coronary artery disease, smoking and dialysis vintage.
Level of evidence: level 2A
Marius Badal
2 years ago
Summary:
Introduction:
Graft survival in kidney transplant is important to ensure that patients do not return to dialysis and do not need another kidney or to avoid re-transplant. Kidney transplantation has remained the highest graft survival when compared with other organs. With studies and investigations, clinicians will try to better understand the possible risk factors that can contribute to graft loss.
How the study was conducted?
Information was gathered from Cochrane central register for control trials and the Cochrane database between the period of 200-2017.
Studies evaluated 18 kidney recipients for their first transplant and evaluated the association between the risk factors and the possible 1-year graft loss.
Quality in prognostic studies instrument was used to assess the individual risk bias and the bias risk was classified as low or high.
The investigators applied the grading recommendations assessment development and evaluation (GRADE) assessment in this study.
What was the result of the study?
There were 19679 citations that were identified and 35 of them proved eligible.
The six factors identified were the donor age, extended criteria donor, deceased donors, number of HLA mismatch, Recipient age and delayed graft function, and five variables associated with 1-year graft loss were donor sex, done BMI, the years on dialysis, smoking, and coronary disease.
There was no significant association between the donor serum creatinine level and the possible risk factor of 1-year graft loss.
The study also excluded any association of the following with 1-year graft loss which was the cold ischemic time, the age of the recipient, the BMI of the recipient, and if the recipient has DM and HTN.
Study limitation:
The limitation of the study was that the study identifies risk factors using COX regression analysis for graft loss at the time points in follow-up were included.
The potential candidates for transplant may be rejected due to patient factors not being included.
The quality of the review was dependent on UNOS registry studies.
Studies variations in their predictive models.
Study strength:
The use of the GRADE system
There was a large scale that addressed the possible risk factors associated with the 1-year graft loss.
The use of vigorous meta-analytic methods.
Conclusion:
The study conducted has identified the possible risk factors that can affect the 1-year graft survival after kidney transplantation. Recognizing these risk factors will help physicians to make better decisions as to patient selection.
Assafi Mohammed
2 years ago
Summary of the article Risk Factors for 1-Year Graft Loss After Kidney Transplantation
This is a retrospective study, analyzed controlled trials and systematic reviews for citations between the years 2000–2017, looking for risk factors of graft loss 1-year after kidney transplantation. Study’s results and outcome: 1. The number of HLA mismatches was the only risk factor, for which there was an observed association beyond chance, with 1-year death-censored graft loss. 2. There was no statistically significant association between donor serum creatinine level and the risk of 1-year graft loss. 3. There was no significant association between cold ischemia time and graft loss. 4. The review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: · The donor’s age. · Extended criteria donors. · Deceased donors. · Increasing number of HLA mismatches. · The recipient’s age. 5. The study identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: · Donor sex. · Donor BMI. · Recipient’s number of years on dialysis. · History of smoking. · History of coronary artery disease. 6. With high certainty, the study’s findings exclude any association of the following variables with 1-year graft loss: · Increasing cold ischemia time. · Recipient’s age. · Recipient’s BMI. · Recipient’s diabetes. · Recipient’s hypertension. The surprise of this study; to find no evidence of an association between donor creatinine and 1-year graft loss. The explanation for this surprise is as follows: · The inclusion of patient mortality may explain the lack of association between donor creatinine and mortality (it is possible that worse functioning kidneys would not be associated with patient mortality because of the availability of kidney replacement therapies in the event of graft failure). · Possibly, donors with high creatinine were not selected for transplantation, thus eliminating any association beyond chance. · The association between donor creatinine and 1-year graft loss is partially captured by the significant association between extended criteria donor as a risk factor for 1-year graft loss. Conclusion: The followings predicted 1-year graft survival: recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function. What is the level of evidence provided by this article
This is a retrospective study.
Level of evidence grade 3.
Mohamad Habli
2 years ago
The provided article is a meta-analysis with level of evidence II
Introduction
Maximizing graft longevity is the primary goal of therapy following kidney transplantation. Determining low-risk and high-risk transplant patients is crucial. There are models that help predict graft failure one year after transplantation, but their effectiveness is limited since risk variables vary.
To help construct a prediction model that would more accurately assess the significance of significant risk factors for kidney graft survival at one year following transplant, a meta analysis and systematic review were conducted.
Methodology
For citations between 2000 and 2017, the data sources were MEDLINE, EMBASE, the Cochrane central register for controlled trials, and the Cochrane database for systematic reviews.Using the Quality in Prognostic Studies tool, the risk bias for each study was evaluated.
Results
19,679 citations were retrieved in the literature search, out of which 2220 needed a full text review and 35 studies qualified. Patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Portugal, Spain, South Korea, Taiwan, the United Kingdom, and the United States participated in the investigations.In the original investigations, five of the six donor characteristics—donor type, donor quality, donor age, donor sex, and donor body mass index—were found to be independently related to graft loss at one year.
A 1 year death censored graft loss was exclusively associated with the amount of HLA mismatches, according to the meta-analyses of transplant process parameters. The duration of cold ischemia did not significantly correlate with graft loss.
Recipient age, pretransplant smoking, pretransplant recipient coronary artery disease, and number of pretransplant years on dialysis were all strongly linked to 1-year death-censored graft loss. Recipient sex, race, BMI, hypertension, or diabetes were not shown to be statistically associated with 1-year graft loss.
Early post-transplant problems linked to death-censored graft loss included acute rejection and delayed graft function.
Discussion
Five risk factors were shown to be connected to 1-year graft loss: recipient age, increasing number of HLA mismatches, extended criteria donors, and donor age. Donor sex, donor BMI, the recipient’s number of years on dialysis, history of smoking, and coronary artery disease were the factors linked to 1-year graft loss.
The review did not find any correlation between 1-year graft failure and increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, or recipient hypertension.
Strengths and weaknesses
The risk variables for graft loss after kidney transplantation after one year have not previously been the subject of a large-scale, systematic review like this one. It was possible to report on the strength and direction of associations for each risk factor thanks to the GRADE methodology.
Its scope was constrained by the use of Cox regression analysis, which presupposed that the primary study authors had verified and evaluated the proportional hazards assumption required for the accuracy of any stated hazard ratios. Another drawback was the possibility that patients’ variables would cause transplant candidates to be passed up.
Conclusion
This review has demonstrated that a number of recipient and donor variables raise the possibility of graft loss following transplantation. To assist clinicians in choosing transplant patients, it is critical to anticipate the probability of graft loss.
Age of recipient, age of donor, donors that meet extended criteria requirements, deceased donors, and an increasing incidence of HLA mismatches are among the risk factors noted.
According to the study, there is no stronger correlation between recipient BMI, recipient diabetes, or recipient hypertension and 1-year graft survival with the increase in cold ischemia time.
hussam juda
2 years ago
INTRODUCTION
· Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
· After expansion of the pool of kidney grafts, 1-year graft survival needs reevaluation
· This is a review to assess the predictive power of key risk factors for kidney graft survival at 1-year post-transplant
Materials and Methods
· Data Sources and Searches: MEDLINE, EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations between the years 2000–2017
· Study Selection and Data Extraction: observational studies of adult (> or18 years) kidney recipients receiving their first transplant
· Data Synthesis and Statistical Analyses: meta-analysis for any risk factor evaluated in two or more studies, was conducted.
– This review addressed two possible subgroup analyses: risk of bias and outcome definition
Results
· Study Selection and Characteristics: 35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
· Risk of Bias of Individual Studies: 18 of the 35 eligible studies, had high risk of bias, most commonly because of limitations in statistical analysis and reporting
· Meta-Analyses of Donor Factors: No statistically significant association between donor serum creatinine level and the risk of 1-year graft loss
· Meta-Analyses of Transplant Process Factors: The number of HLA mismatches was the only risk factor with 1-year death-censored graft loss
· Meta-Analyses of Recipient Factors: Four of the nine transplant recipient variables were significantly associated with 1-year death-censored graft loss: recipient age, pretransplant smoking, pretransplant recipient coronary artery disease, and number of pretransplant years on dialysis
· Meta-Analyses of Post-Transplant Complications: significant association with 1- year graft loss: delayed graft function and acute rejection
Discussion
· Five risk factors were identified to be associated with 1-year graft loss: 1) donor age 2) extended criteria donors 3) deceased donors 4) increasing number of HLA mismatches 5) recipient age.
· Five variables were associated with 1-year graft loss: 1) donor sex 2) donor BMI 3) recipient’s number of years on dialysis 4) history of smoking 5) coronary artery disease
· Variables not associated with 1-year graft loss: 1) increasing cold ischemia time 2) recipient age 3) recipient BMI 4) recipient diabetes 5) recipient hypertension
Strengths of the study:
· first large, systematic review of studies of risk factors for 1-year graft loss after kidney transplantation
· Using rigorous meta-analytic methods, the review provides precise measures, for the association of each risk factor and graft loss, informed by observational cohort studies
· The use of GRADE methodology
Limitations of the study:
· The author included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up
· Quality of this review is dependent upon the quality of the UNOS registry data only
· The effect of a particular risk factor might differ depending on which variables were included in a particular model
What is the level of evidence provided by this article?
Prospective cohort study, evidence 2
Rihab Elidrisi
2 years ago
Many patients will have long waitting list because of limited kidneys ● kidney recipients have the highest rate of graft survival among all organs transplanted 92% 1-year graft survival for kidneys transplanted from deceased donors ● studies included patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and United States. ● All studies defined extended criteria donors as .60 years of age or age 50–59 years with two of three associated risk factors: history of cerebrovascular accident, hypertension, or serum creatinine .1.5 mg/dl ● delayed graft function as the need for dialysis within the first week post-transplant. ● five risk factors have moderate to high certainty association with 1-year graft loss: ** donor age
Hadeel Badawi
2 years ago
Graft longevity becomes a care focus, as graft loss results in significant morbidity and mortality. Graft survival is subject to changes, especially with the increasing use of marginal donors.
The objective of our study:
To evaluate factors influencing the risk of 1-year graft loss in kidney transplant recipients.
Materials and Methods:
Search in databases from 2000 to 2017 and included:
Observational studies of adult KTR of their first transplant
That measure the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss using multivariable analysis.
The risk of bias was assessed using the Quality in Prognostic Studies instrument.
Six factors were associated with graft loss, with a moderate to a high degree of certainty:
-Donor age HR1.11 per 10-year increase;
-Extended criteria donors HR, 1.35.
-Deceased donors HR, 1.54.
-Number of HLA mismatches HR, 1.08 per one mismatch increase.
-Recipient age HR, 1.17 per 10-year increase
-Delayed graft function HR, 1.89
Identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss:
Donor sex
Donor BMI
Pre-transplant smoking HR, 1.59 moderate certainty due to serious imprecision.
Pre-transplant recipient CAD HR, 1.15; moderate certainty due to serious indirectness.
The number of pre-transplant years on dialysis HR, 1.03 per 1-year, increases moderate certainty due to serious risk of bias.
Pooled analyses also excluded with a high degree of certainty, any associations with 1-year graft loss.:
-Cold ischemia time
-Recipient race
-Pre-transplant BMI
-Diabetes.
-Hypertension.
Conclusions:
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted1-year graft survival. The effect of each risk factor is small
Strengths:
-a large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after KT.
– The review provides precise measures compared with any individual study.
– The use of GRADE methodology enabled us to report on the certainty of the evidence
Limitations:
-It is limited by studies using Cox regression analysis for graft loss at all times in follow-up. Therefore, we assumed
that the authors had tested and ensured the hazards assumption necessary for the validity of any reported HR.
– Studies varied in the covariates included. Thus, results are vulnerable to the possibility that the effect of a particular risk factor
might differ depending on which variables were included in a particular model.
Level of evidence: 2a
Heba Wagdy
2 years ago
Several recipient and donor factors increase the risk of graft loss, theses factors may not be clinically important to avoid the benefit of transplantation, so determining the factors associated with graft loss is important to improve graft outcome.
Risk prediction models are needed to guide the selection of candidates whose risk of graft loss is higher than the risk of mortality on dialysis.
This meta analysis aims to assess the predictive power of risk factors for graft survival at one year.
The authors searched bibliographic databases between 2000 to 2017.
It included observational studies, 35 eligible studies were included and meta analysis for any risk factor evaluated in 2 or more studies.
It identified 5 risk factors with high certainty of association with one year graft loss, donor age, extended criteria donor, deceased donor, increased number of HLA mismatches and recipient age.
It showed 5 risk factors with moderate certainty of association, donor rsex, donor BMI, numbers of years the recipient remained on dialysis, history of smoking and coronary artery disease
There was no association between one year graft survival and prolonged cold ischemia time, recipient age, recipient BMI, recipient DM and recipient HTN. Strengths:
Large scale systemic review.
The estimates in the study can be multiplied by HR of multiple risk factors to get the combined effect on the risk of 1-year graft loss.
Provided precise measures for the association of each risk factor and graft loss informed by observational cohort studies.
Used GRADE methodology which allowed assessing the magnitude of the association of each risk factor and allowed reporting the certainty of the evidence. Limitations:
Included studies that identified risk factors using cox regression analysis for graft loss at all time points in follow up, so the statistical analysis of risk of bias assessment was not fully informed by meeting regression model assumptions.
Included UNOS registry studies, so quality of the review is dependent on quality of UNOS registry data which is characterized by limited control over data collection compared to single and multicentered observational studies.
Studies included have different covariates so the effect of particular risk factor may differ according to the variable included in a certain model.
Studies included have a limitation as potential recipients may be rejected because of patient factors that were not included and these factors may be determinant of the outcome.
Level of evidence: 2a (meta analysis of observational cohort studies, no RCT were included)
Abdul Rahim Khan
2 years ago
Please summarise this article The purpose of this study was to evaluate the risk factors of graft loss at 1 year post kidney transplant. Methodology Data base from 2000-2017 was searched and it included observational studies . these t measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss. Results and conclusions 35 studies- 20 risk factors amenable to meta analysis. 6 factors associated with graft loss- Donor age ECD Number of HLA mismatches Recipient age Delayed graft function Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small. What is the level of evidence provided by this article? Level 2a
Hussein Bagha baghahussein@yahoo.com
2 years ago
Introduction
After kidney transplantation, the focus of care is mainly on maximizing graft longevity. It is therefore important to identify low-risk and high-risk transplant cases. There are existing models that assist in prognosticating graft loss 1 year post transplantation, but they have limited performance as risk factors are varied.
The meta analysis and systemic review was performed to guide the development of a prediction model that would better asses the power of key risk factors for kidney graft survival at 1 year post transplant.
Methodology
The data sources were the MEDLINE, EMBASE, Cochrane central register for controlled trials and the Cochrane database for systematic reviews for citations between 2000 and 2017.
The risk bias for individual studies was assessed using the Quality in Prognostic Studies instrument.
Results
The literature search found 19,679 citations out of which 2220 required a full text review, 35 studies proved eligible. The studies included patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom and the United States.
The review assessed six donor characteristics, five were independently associated with 1-year graft loss in the original studies: donor type, donor quality, donor age, donor sex, donor body mass index.
The meta-analyses of transplant process factors showed that the number of HLA mismatch was the only risk factor that was associated with a 1 year death censored graft loss. There was no significant association between cold ischemia time and graft loss.
The meta-analyses of recipient factors identified factors that had been investigated in two or more of the primary studies. They were significantly associated with 1-year-death-censored graft loss and included recipient age, pretransplant smoking, pretransplant recipient coronary artery disease, and number of pretransplant years on dialysis. No statistical significant association was observed for recipient sex, race, BMI, hypertension or diabetes with 1-year graft loss.
Delayed graft function and acute rejection were the early post-transplant complications associated with death-censored graft loss.
Discussion
The review identified five risk factors that were associated with 1-year graft loss: donor age, extended criteria donors, increasing number of HLA mismatches and recipient age. The variables associated with 1-year graft loss included donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking and coronary artery disease.
The review excluded any association of increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes and recipient hypertension with 1-year graft loss.
Strengths and limitations
This study is the first large-scale, systematic review addressing risk factors for 1-year graft loss after kidney transplantation. The use of GRADE methodology enabled to report on magnitude and direction of association for each risk factor.
It was limited by the use of Cox regression analysis, which assumed that the authors of the primary studies had tested and ensured the proportional hazards assumption necessary for validity of any reported hazard ratios. Another limitation was that the potential candidates for transplant may be rejected because of patient factors that were not included.
Conclusion
From this review, it is shown that many recipient and donor characteristics increase the risk of graft loss after transplantation. It is important to predict the risk of graft loss in order to guide clinicians in selection of candidates for transplantation.
The risk factors identified include: recipient age, donor age, extended criteria donors, deceased donors and increasing number of HLA mismatches.
The study also established that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have an increased association with 1-year graft survival.
Level Of Evidence
This is a meta analysis so the level of evidence is 1
saja Mohammed
2 years ago
Summary This is a review article of many observational studies through database search between 2000-2007 and they include only 35 studies from the search of > 19000 studies addressing the risk factors that might affect the 1-year graft survival (its prognostic type of study) that can help and guide us to identify short and long-term risk factors in the first year after transplantation that can impact the graft survival This review addressed two possible subgroup analyses: risk of bias and outcome definition. Method Materials and setting Data sources
Systemic review through the Embase, and Midline search from controlled registered trials, Cochrane, search for systemic reviews including citation between 2000-2007
Selection criteria include all observational studies that address the risk factor got graft loss after 1 year from transplantation for adults > 18 years old including cited reviews and unpublished studies, they did not restrict to language in their search to asses risk selections bias between studies they use quality in prognostic studies tools also they report the statistical heterogenicity over visual inspection of forest plots, observing for the reliability of point estimates and the range of overlap in confidence intervals.
There is heterogenicity in trails design and selections criteria, immunosuppression protocols diverse populations Risk of bias
Out of 35 eligible studies still, 18 studies have a high risk of bias due to imitation in statistical analysis
They identify 20 risk factors in relation to the donor like donor age, ECD, BMI Deceased vs living donor, recipients’ risks like age and comorbid, immunological risks like numbers of HLA mismatches, complications like DGF, Results in this review, they reported five risk factors associated with moderate to high certainty in the value of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, an increasing number of HLA mismatches,and recipient age
10 risk factors are associated with a high to moderate high of graft concerning death in the first year after transplantation including donor age and ECD, DD also old recipient, numbers of HLA mismatches, and DGF as a complication. no evidence of an association between donor creatinine and 1-year graft loss. This can be explained in part that donors with high creatinine were excluded from the donation also the inclusion of patient mortality may explain the lack of association between donor creatinine and mortality. However, in one report they acknowledged that donor eGFR .60 ml/min per kilogram is associated with a lower risk of graft loss at 1-year post kidney transplantation
Strength of the study
Large sample size with a diverse population
A systemic review of only adjusted indications for the predictive risk factors by using hard data analysis methods to adjust for risks of bias including the use of GRADE methodology
Limitations
There is heterogenicity in trails design and selections criteria, risk stratifications, short fu for certain risk factors, and outcome Bias with risk prediction models and moderate to the serious inconsistency in the quality of evidence
1. In this review, a short follow-up time of 1 year may explain the lack of association beyond the chance for recipient sex and graft loss
2. Failed association between race and graft loss can be explained by the falling racial difference in kidney transplantation.
3. discrimination and standardization of Cox regression analysis for graft loss at all time points in follow-up.
4 Including large registry data including UNOS so the quality of the study may depend on the quality of registry data.
however, this review indicates the need for future research with better design of risk prediction models including cardiovascular disease with longer follow-up to guide clinicians in their selection of candidates whose risk for graft loss may be higher than their risk of mortality on dialysis
What is the level of evidence provided by this article?
review from observational cohort studies including heterogenous, unpublished studies despite the systematic review, and including big registry data that might mask the quality of evidence still can not be of level l, no single RCT included.
level 2 A
Last edited 2 years ago by saja Mohammed
Huda Mazloum
2 years ago
● Many patients will have long waitting list because of limited kidneys
● kidney recipients have the highest rate of graft survival among all organs transplanted 92% 1-year graft survival for kidneys transplanted from deceased donors
● studies included patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and United States.
● All studies defined extended criteria donors as .60 years of age or age 50–59 years with two of three associated risk factors: history of cerebrovascular accident, hypertension, or serum creatinine .1.5 mg/dl
● delayed graft function as the need for dialysis within the first week post-transplant.
● five risk factors have moderate to high certainty association with 1-year graft loss: ** donor age
**extended criteria donors
** deceased donors
** increasing number of HLA mismatches,
** recipient age
● An additional five variables have moderate certainty association with 1-year graft loss:
** donor sex
** donor BMI
** recipient’s number of years on dialysis,
** history of smoking
** coronary artery disease
● With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss:
** increasing cold ischemia time
** recipient age
** recipient BMI
** recipient diabetes
** recipient hypertension.
● limitation
** The authors of the individual studies
seldom reported on assessing the necessary assumptions of their regression models.
** statistical analysis for the risk of bias assessment could not be fully informed by
meeting the regression model assumptions
** the quality of this review is dependent upon the quality of the UNOS registry data. ** more likely to ensure data quality before analysis of risk factors
** results are vulnerable to the possibility that the effect of a particular risk factor
might differ depending on which variables were included in a particular model.
** studies in this review have a fundamental limitation:
** potential candidates for transplant may be rejected because of patient factors
that were not included.
● present storage techniques such as machine perfusion and preservation solutions minimize cold ischemia damage to the kidney
Level :2
Sahar elkharraz
2 years ago
This article is systemic review and meta analysis done between 2000 to 2017 address risk factors of kidney loss and compression between recipient and donor graft survival.
Kidney transplant is a successful operation in compare to all organ transplant which reach to 92%. The fate of kidney graft loss is dialysis or retransplant and death.
There’s 5 donor risk factors associated with graft loss is age/ sex (female) probably increase risk of graft loss / BMI more than 30, increase risk of graft loss and delay graft function required dialysis within one week post transplant. Extended donor criteria is age more than 60 years or age between 50 to 59 years associated with 2 to 3 comorbidites like cerebrovascular accidents or diabetes and hypertension or creatinine level more than 1.5 mg/ dl. All this factors contribute for graft loss.
Transplant process factors// This study shows no significant increase of cold ischemic time long in one hour and graft loss despite donor age and sex / donor type and donor cause of death and history of early graft rejection and evidence of cardiovascular disease and donor HLA mismatch. The number of HLA mismatch carriers high risk of graft loss.
Also type of donor whether living or deceased has role in graft loss since deceased donor increase risk of graft loss.
Recipient risk factors:
This study address nine factors four of them are highly risk of graft loss in one year. There are recipient age / number of pre transplant dialysis duration and pretransplant smoking and pretransplant coronary arteries disease. However pretransplant smooking and coronary arteries disease contribute for graft loss.
There’s no significant associated between sex and race of recipient and BMI and presence of hypertension and diabetes in graft loss within one year.
Pist transplant complications:
This study also address the associated with delay graft function and acute kidney rejection. However both increase rate of graft failure.
Finally it’s large systemic review and meta analysis identify ten risk factors for evaluate graft function loss in one year post transplant age, sex, race of donor and recipient , duration of dialysis pre transplant and number of HLA mismatch and type of donor and extended criteria of donor. increase cold ischemic time.
Q2: level 2
Reem Younis
2 years ago
Please summarise this article
-Graft loss results in return to dialysis, retransplantation, or death.
-Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors .
– It is bibliographic databases from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss
-This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age.
-Other variables for which, with moderate certainty, there is
an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease.
-The increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival. Strengths and Limitations
–Strengths:This study is the first large-scale, systematic review of
studies that have conducted adjusted analyses addressing
risk factors for 1-year graft loss after kidney transplantation.
-The use of GRADE methodology enabled them to not only report on the direction and magnitude ofthe association for each risk factor, but also to transparently report on the certainty of the evidence.
–Limitations :they included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
-The quality of this review is dependent upon the quality of the
UNOS registry data. What is the level of evidence provided by this article?
Level 1
Dear Dr Reem, I like your analysis and report. This study provides levels 2A evidence, please read my response to Dr Ghalia. Ajay
mai shawky
2 years ago
club 4, risk factors for graft loss in 1st year post transplant summary:
· The current study aimed to evaluate the risk factors for graft loss and found that:
o The age of both the donor and recipient, standard versus extended criteria donor, living versus deceased donor, degree of HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small.
o However, cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension have no effect on the graft survival at one year.
· Level of evidence: although they say that it is systemic review and meta-analysis, but (garbage in, garbage out). The included studies in the current analysis are all retrospective cohort, so at best level of evidence it is just level 2.
Hi Dr Shawky,
2a rather than 2 will be better way of stating the level of evidence.
Ajay
Ajay Kumar Sharma
Admin
2 years ago
Dear team, This is just a copy of what I replied to our colleague, Dr Ghalia,
I must say that you analysis I regards to the level of evidence this study provides is most wonderful. This triggers me to correct my response to level 2a rather than level 1a. I like you contention as described in GIGO (garbage in, garbage out) for meta analyses. The level of meta analysis is as good as the articles used. If it has used poor quality studies it would become the level ‘a’ of the level of those studies. Since this study includes cohort studies, it would qualify for a 2A level at the best. I do not know where there are studies that are case-control studies in this meta-analysis, the description is not so complete in this regard. To give the benefit of doubt, all the studies included would be cohort since they are talking about HR (there would be a time-line that subject are exposed to a hazard), not odds ratio (as in case-control). Ajay
Ghalia sawaf
2 years ago
Materials and Methods
Data Sources and Searches
MEDLINE, EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations between the years 2000–2017.
Study Selection and Data Extraction
selected observational studies of adult (>18 years) kidney recipients receiving their first transplant, including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis.
Risk of Bias of Individual Studies
Quality in Prognostic Studies instrument
Data Synthesis and Statistical Analyses
The included studies reported point estimates and 95% CIs as (HRs), (ORs), or (RRs).
included ORs and RRs in the same meta-analysis without conversion
When we observed a clinically or statistically significant difference between binary (e.g., OR or RR) and we converted the OR or RR to HR
When the subgroup analysis for risk of bias and outcome definition showed a significant difference across groups, we applied the (GRADE) assessment
We applied a two-sided P value of #0.05 to denote statistical significance.
Results
Study Selection and Characteristics
19,679 unique citations,
of which 2220 citations required full text review;
35 studies ultimately proved eligible
from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and United States.
Risk of Bias of Individual Studies
18 Studies to have high risk of bias most commonly because of limitations in statistical analysis
Across the many risk factors included in this review, only the subgroup analyses for risk of bias in recipient diabetes and delayed graft function showed statistically significant different effect
we only utilized estimates from low risk of bias stud
Meta-Analyses of Donor Factors
The review assessed six donor characteristics:
1. donor type (HR, 1.54 for deceased donors; 95% CI, 1.32 to 1.82; high certainty),
2. donor quality (HR, 1.35 for extended criteria donors; 95% CI, 1.28 to 1.42; moderate certainty due to risk of bias),
3. donor age (HR, 1.11 per 10-year increase; 95% CI, 1.04 to 1.18; high certainty),
4. donor sex (HR, 1.10 for female sex; 95% CI, 1.07 to 1.21; moderate certainty due to serious inconsistency),
5. donor (BMI) (HR, 0.90 per 10 kg/m2 increase; 95% CI, 0.82 to 0.91; moderate certainty due to serious risk of bias).
all studies defined extended criteria donors:
More than 60 years of age
or age 50–59 years with two of three associated risk factors:
• history of CVA
• hypertension,
• serum creatinine .1.5 mg/dl
delayed graft function the need for dialysis within the first week post-transplant.
Meta-Analyses of Transplant Process Factors
two risk factor variables characteristic of the transplant process .
The number of HLA mismatches was the only risk factor, for which we observed an association beyond chance, with 1-year death-censored graft loss (HR, 1.08 per one mismatch increase; 95% CI, 1.07 to 1.09; high certainty).
We observed no significant association between cold ischemia time (HR, 1.00 per 1-hour increase; 95% CI, 0.99 to 1.00) and graft loss
Meta-Analyses of Recipient Factors
We identified nine transplant recipient variables
Four of the nine were significantly associated with 1-year death-censored graft loss:
1. recipient age (HR, 1.17 per 10-year increase; 95% CI, 1.09 to 1.25; high certainty),
2. pretransplant smoking (HR, 1.59; 95% CI, 1.34 to 1.90; moderate certainty due to serious imprecision),
3. pretransplant recipient coronary artery disease (HR, 1.15; 95% CI, 1.03 to 1.27; moderate certainty due to serious indirectness),
4. number of pretransplant years on dialysis (HR,1.03per1-year increase; 95% CI, 1.02 to 1.03; moderate certainty due to serious risk of bias).
Meta-Analyses of Post-Transplant Complications
DGF – AR
early post-transplant complications associated with death-censored graft loss
For both, we observed a statistically significant association with1year graft loss:
• DGF (HR, 1.89; 95% CI, 1.46 to 2.47; moderate certainty due to serious inconsistency) and
• AR (HR, 3.16; 95% CI, 1.86 to 5.38; moderate certainty due to serious inconsistency).
Strengths and Limitations
This study is the first large-scale systematic review of studies that have conducted adjusted analyses addressing risk factors for1-year graft loss after kidney
The review provides precise measures, compared with any individual study,
The use of GRADE methodology
One limitation of this review is that we included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
We included (UNOS) registry studies
Studies varied considerably in the covariates included in their predictive models
In the contex to identifying factors that increase the risk of graft loss in the year after transplant, the studies in this review have a fundamental limitation: potential candidates for transplant may be rejected because of patient factors that were not included. The reasons for not recommending transplant in such individuals may be the most powerful determinants of outcome
Some may be surprised that cold ischemia time was not associated with1-year graft loss.
Plausible explanation is that techniques such as machine perfusion and preservation solutions minimize cold ischemia damage to the kidney
Dear Dr Ghalia,
I must say that you analysis I regards to the level of evidence this study provides is most wonderful. I like you contention as described in GIGO (garbage in, garbage out) for meta analyses. The level of meta analysis is as good as the articles used. If it has used poor quality studies it would become the level ‘a’ of the level of those studies.
Since this study includes cohort studies, it would qualify for a 2A level at the best. I do not know where there are studies that are case-control studies in this meta-analysis, the description is not so complete in this regard. To give the benefit of doubt, all the studies included would be cohort since they are talking about HR (there would be a time-line that subject are exposed to a hazard), not odds ratio (as in case-control). Ajay
Summary of the article; Although The kidney transplantation considered the best treatments of renal failure, successful of kidney transplantation is of great concern, studies, researches, which results in improving short and long term outcome and overall improving quality of life and recipients satisfaction. With expanding the donor pool according to increasing demand by using ECD and poor quality kidneys to improve quality of life and to reduce waitlisting patients on dialysis. So with improving managing grafted kidney 1 year graft survival is of great developing with good outcome. Applied guidelines can aid clinicians to follow a proper approach regarding surgical and medical area of care. Materials and Methods; Data sources; Collected from bibliographic databases in February 2017;
MEDLINE.
EMBASE.
Cochrane central register for controlled trials.
Cochrane data base for systematic reviews for citations between the years 2000-2017.
Study selection and data Extraction;
Observational studies of adult >/ 18 years kidney recipients receiving their first transplant, including evaluating tha association between any risk factors and 1 year graft loss.
No restriction by language or publication status.
Abstracts that met the inclusion criteria of this article , and provided enough information were included.
Risk of bias of individual studies; Risk of bias had been assessed using the Qulaity in Prognostic studies instrument. Results;
The study selection and characteristics; 19679 citation was identified, 2220 citation required full text review. 35 studies were eligible.
Risk of bias of individual studies; Among 35 eligible studies, reviewers reported 18 to have high risk of bias, most commonly because of limitations in statistical analysis, and reporting.
11 variables were included among the studies.
Metanalysis of donor factors; The review assessed 6 risk donor characteristics, Five were independently associated with 1-year graft loss; (Donor type, Donor quality, Donor age, Donor sex, and Donor BMI.
All studies; Defined ECD as >60 years of age, or age 50-59 years with 2 of 3 associated risk factors, (CVD, HTN, Cr >1.5 mg/dl, or DGF).
Metanalysis of transplant process factors; Tow risk factors was assessed, (the number of HLA MM, the only risk factor that fund to be associated with 1-year death-censored graft loss. No ass between CIT and graft loss.
Meta-Analysis of Recipients factors; $4$ factors was significantly ass with 1-year death-censored graft loss;(Recipient age, PreTx smoking, PreTx CAD, No of preTx years on Dx.
Meta-Analysis of post Tx complications; DGF and early AR as early post Tx complication that ass with death-censored graft loss.
Discussion;
In this review we found that 5 risk factors are variably ass with the 1-year graft loss; (Donor age, ECDs, DDs, HLA MM, and recipient age).
Moderate risk ass between 1-year graft loss, (Donor sex, Donor BMI, Recipient number of years on Dx, Hx of smoking, and CAD.
No ass between following factors and risk of 1-year graft loss; (CIT, Recipient age, recipient BMI, Recipient DM, and Recipient HTN).
Strength of the study;
Large scale addressed risk factors ass with 1 year graft loss, with multiple users estimates.
Using rigorous Meta-analysis methods, the review provide precise measures compared with any individual study for associations.
The use of GRADE methodology.
Limitations;
Including of the study using Cox regression analysis for graft loss in all time pointed follow up.
Statistical analysis for the risk of bias assessment could not be fully informed by meeting the regression model assumptions.
Quality of the review was dependent on UNOS registry studies.
Studies variations in their predictive models.
Rejection of potential candidates for Tx because of factors that was not included.
I like your analysis and report.
This study provides levels 2A evidence, please read my response to Dr Ghalia. Ajay
Last edited 2 years ago by Ajay Kumar Sharma
Esraa Mohammed
2 years ago
*Kidney transplant recipients have the highest rate of graft survival among all organs transplanted : 92% 1-year graft survival for kidneys transplanted from deceased donors.
* 1-year graft survival may change. It is therefore useful to identify low-risk and high-risk kidney transplant cases.
Materials and Methods
* MEDLINE,EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations between the years 2000–2017.
* selected observational studies of adult (>18 years) kidney recipients receiving their first transplant, including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis.
* assessed the risk of bias of individual studies using the
Quality in Prognostic Studies instrument
* conducted meta-analysis for any risk factor evaluated in two or more studies.
Results
*Study Selection and Characteristics, The individual studies included patients from diferent countries.
*Risk of Bias of Individual Studies
Of the 35 eligible studies, reviewers judged 18 to have
high risk of bias
*Meta-Analyses of Donor Factor
The review assessed six donor characteristics; five were
independently associated with 1-year graft loss in the
original studies and also proved predictive in the metaanalysis (donor type, quality,age, sex, BMI)
*Meta-Analyses of Transplant Process Factors
risk factor variables characteristic of thetransplant process
-HLAmismatches
-cold ischemia time
-recipient sex,BMI,DM, dialysis, comorbidities, delayed graft , early acute rejection.
*Meta-Analyses of Recipient Factors
nine transplant recipient, Four of the nine were significantly associated with 1-year death-censored graft loss: recipient age, pretransplant smokingpretransplant recipient coronary number of pretransplant years on dialysis artery disease,
We did not observe a statistically significant association for recipient sex, race, BMI, hypertension, or diabetes with 1-year graft loss . We did not detect publication bias
for any of the recipient factors.
*Meta-Analyses of Post-Transplant Complications
For both, we observed a statistically significant association with 1- year graft loss:
delayed graft function and acute rejection
We did not detect publication bias for any of the post-transplant complication factors.
*Risk Factors Addressed in a Single Study
This review identified an additional 72 candidate risk factors, each evaluated in only one study.
Conclusion:
Risk facters associated with moderate to high 1- year graft loss are associated with recepient sex,Years on dialysis for recipient , donor extended criteria, high bmi, deseased donor.
Risk facters asscociated with high 1- yr graft loss are:
Donor age, deseased donors, cold ischemia time, HLA mismatch, increase recipient age, race, bmi, diabetes.
Hi Dr Esra, I like that your headings in bold. Your sub-headings too should be in bold or underline. That will make it easy to read. Ajay
abosaeed mohamed
2 years ago
This review aims to evaluate the factors that supposed to influence the risk of one year graft loss in kidney transplant recipients .
– Design, setting, participants, & measurements:
databases from 2000 to 2017 , included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
– Results:
· 35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
· Six factors were associated with graft loss, with moderate to high degree of certainty: donor age 1.11 per 10-year increase, extended criteria donors, deceased donors , number of HLA mismatches , recipient age , and delayed graft function as risk factors for 1-year graft loss.
· Pooled analyses also excluded, with a high degree of certainty, any associations of cold ischemia time, recipient race, pretransplant body mass index, diabetes, and hypertension with 1-year graft loss.
– Conclusion :
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
doaa elwasly
2 years ago
Introduction
Prolongation of graft survival post transplantation is a crucial issue to avoid redialysis , retransplantation or death.
Renal graft survival is the highest among all organs transplanted,
Meanwhile 1 year graft survival is variable according to high or low risk kidney transplant cases.
Risk prediction models have limited performance as they cannot be generalised.
A meta-analysis can guide the development of a prediction model with useful discrimination and calibration . Methods
Data was obtained from MEDLINE, EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations within 17 years including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis.
GRADE approach rating the certainty of evidence was used. Results
Out of 35 eligible studies 18 had high bias risk.
Recipient diabetes and delayed graft function showed statistically significant different effect estimates in studies at high versus low risk of bias.
Donor type either deceased or living , donor quality either extended or standard , donor age, donor sex and BMI are independently associated with 1-year graft loss with different degree of certainty.
There was no significant association between donor serum creatinine level and the risk of 1-year graft loss.
HLA mismatches numbers was the only risk factor associated with 1-year death-censored graft loss.
Cold ischemia time wasnot associated with graft loss.
Recipient age, pretransplant recipient smoking, pretransplant coronary artery disease and number of pretansplant years on dialysis were significantly associated with 1-year death-censored graft loss.
Recipient sex, race, BMI, hypertension, or diabetes were not associated with 1-year graft loss.
Delayed graft function and acute rejection were considered as early post-transplant complications associated with death-censored graft loss. Discussion
Strengths were that it is the first large-scale, systematic review of
studies that adjusted analyses for risk factors for 1-year graft loss post kidney transplantation.
These estimates can be useful by multiplying the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss.
GRADE method that was used facilitated detection of direction ,magnitude of association of each risk factors as well as certainty degree.
UNOS registry was included representing a highly referred to source by the transplant community.
The limitation is that included studies identified risk factors using Cox regression analysis for graft loss at all time points in follow-up thereby supposing that the studies authors ensured the proportional hazards assumption necessary for validity of any reported HR.
Also potential candidates for transplant can ne declined because of patient factors that were not included which could be the most important determinant of the outcome.
Cold ischemia was not associated with 1 year graft loss could be due to till a certain duration, there may be no relation between ischemia time and outcome, but beyond that duration graft longevity diminishes.
Other studies declared ischemia time can be associated with 1 year graft loss after a long period of time .
Out of the 34 identified models, 7 only predicted graft loss at 1-year
post-transplantation.
This review excluded an association beyond chance for each of these risk factors and 1-year graft loss.
Opposite to other studies this review excluded an association beyond chance for factors including recipient sex,age , BMI,DM,HTN,donor creatinine and cold ischemia time.
Inspite that other studies mentioned female gender association with better graft outcome due to hormonal effect , while this study did not reveal association due to the study short period .
Also lack of association with race due to lack of race disparities in kidney transplantation studies.
The inclusion of patient mortality may explain the lack of association between donor creatinine and mortality and cases with high creatinine were excluded.
Donor eGFR more than 60 ml/min /kg were associated
with a decrease in risk of graft loss at 1-year postkidney transplantation. Guidelines implications
Risk prediction models to direct selection of candidates whose risk for graft loss can be higher than their risk of mortality on dialysis. Conclusion
10 risk factors associated with 1-year graft survival having moderate or high strength certainty include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches.
Risk factors without large associations with 1-year graft survival having high certainty includes increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension .
-Level of evidence is 5 because the evidence was obtained from systematic reviews of descriptive and qualitative studies
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Nahla Allam
2 years ago
Introduction:
Ø Kidney transplant recipients have the highest graft survival rate among all transplanted organs: 92% 1-year graft survival for kidneys transplanted from deceased donors.
Ø Prognostic studies can guide clinicians and patients in better understanding factors associated with a higher risk of graft loss in the first year post-transplantation.
Materials and Methods:
Ø Cochrane central register for controlled trials and Cochrane database for systematic reviews for citations between 2000 and 2017.
Ø Observational studies of adult (18 years) kidney recipients are receiving their first transplant, including studies evaluating the association between risk factors and 1-year graft loss using multivariable analysis.
Ø The Author Applied the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment only to these studies. We used a two-sided P value of <0.05 to denote statistical significance. STATA’s mean function provided the platform for conducting all statistical analyses
Results:
1- 35 eligible studies, reviewers judged 18 to have a high risk of bias
2-The review assessed six donor characteristics; five were independently associated with 1-year graft loss in the original studies and also proved predictive in the meta-analysis
3-All studies defined extended criteria donors as >.60 years of age or age 50–59 years with two of three associated risk factors: history of cerebrovascular accident, hypertension, or serum creatinine .1.5 mg/dl and delayed graft function as the need for dialysis within the first week post-transplant
4-There is no statistically significant association between donor serum creatinine level and the risk of 1-year graft loss
5-The number of HLA mismatches was the only risk factor, for which we observed an association beyond chance, with 1-year death-censored graft loss
6-Not observe a statistically significant association for recipient sex, race, BMI, hypertension, or diabetes with 1-year graft loss
7-Identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease
Strength:
1-large-scale, a systematic review of studies
2-Using rigorous meta-analytic methods
3-The use of GRADE methodology
Limitation :
1- studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Isaac Abiola
2 years ago
SUMMARY
Introduction
The kidney transplantation is the beginning of another journey although with better quality of life as the attention is shifted toward ensuring graft longevity. The scarcity of organ for transplantation has resulted in extended donor criteria to make more organ available but this has also come up with question on the 1- year graft survival compared to organ from standard criteria
Aim of the study
to evaluate factors purported to influence the risk of 1-year graft loss in kidney transplant recipients
Materials and Methods
data source is from EMBASE, MEDLINE, and Cochrane central registral for controlled study from 2000-2017
is an observational study of transplant recipient adult >18 years
Quality in Prognostic Studies Instrument was used to assess the individual risk bias
the bias risk was classified as low or high
Results
of the 19,679 unique citations, 220 citations require full test review and 35 of them provide eligibility with 18 of them adjudged with high risk of bias
donor factors associated with one year graft loss are donor type, donor quality, donor age, donor sex, and donor body mass index.
HLA mismatches is the only transplant process associated with one year graft loss
recipient factors associated with one year graft loss are pre transplant smoking, pre transplant recipient coronary artery disease, number of pre transplant years on dialysis, and recipient age.
Strength of the study
large sample size
the use of GRADE methodology to appreciate the magnitude of associations
Limitation of the study
inclusion of studies identifying risk with use of Cox regression
the use of UNOS registry only which could make the study to repeat same error from the registry
Conclusion
It is of note that this study has been able to report both donor and recipient factors that could affect the one-year graft survival following kidney transplant, and this will help the attending physicians in patient selection for the kidney transplant
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Amit Sharma
2 years ago
Please summarise this article
Kidney transplant is associated with high (92%) 1-year graft survival. It is important to identify high-risk and low-risk kidney transplant cases. The article evaluated 35 studies from multiple countries to assess influence of certain risk factors over 1-year graft loss in kidney transplant recipients. It also included unpublished data from clinical experts. The risk of bias of individual studies was assessed using Quality in Prognostic Studies instrument and GRADE approach was used to assess the certainty of evidence.
Association between graft loss and donor characteristics: Donor age and donor type (deceased) had high certainty association with graft loss while donor quality (extended criteria), donor gender (female) and donor BMI (lower) had moderate certainty association with graft loss. Donor serum creatinine did not have any association with graft loss.
Association between graft loss and transplant process factors: Number of HLA mismatch was associated with high certainty with no effect of cold ischemia time.
Association between graft loss and recipient factors: Recipient age was associated with high certainty, while pre-transplant number of years on dialysis, smoking and coronary artery disease were associated with moderate certainty. Recipient gender, race, BMI, hypertension, and diabetes were not associated with graft loss.
Association between graft loss and post-transplant complications: Acute rejection and delayed graft function were associated with moderate certainty.
Strength of the study: First large scale review, use of GRADE methodology to report on the certainty of the evidence, individual hazard ratios of the risk factors can be multiplied to get combined effect of multiple risk factors.
Limitations of the study: Included unpublished data and included registry data (hence the quality of the review is as good as the quality of the registry data). The included studies varied considerably in the covariates included. Another limitation is because of the nature of the studies, recipients with multiple co-morbidities might not have been included in the transplant program, hence the assessment of effect of multiple risk factors which were not included could not be studied. Another limitation is the nature of the study, looking at only 1-year graft loss data.
Conclusion: 1 year graft loss post kidney transplant depends on donor age, donor type, donor quality, HLA mismatch, recipient age, delayed graft function as well as donor BMI and gender, and recipient coronary artery disease, smoking and dialysis vintage.
2. What is the level of evidence provided by this article?
Level of evidence: level 5 – Narrative review
Although written as systematic review, this does not include any randomized controlled trial. It has also included unpublished studies.
This study is about the factors that might lead to loss of graft within one year post transplant.
Some of the factors that can affect one year graft loss rate are
recipient age
donor age
standard vs extended criteria donor
living vs deceased donor
HLA mismatch
delayed graft function (DGF)
Quantity of time the patient remained on dialysis before kidney transplant. Most patients undergo approximately 10 years of dialysis before kidney transplant.
Cold ischemia time however, has been identified to not be associated with increased risk of graft loss. Machine perfusion might be the answer to this that mitigates risk.
In addition, donor creatinine was found to have no association with 1 year graft loss. However, this could be a false association due to the fact that donors with worse creatinine levels were not selected for transplantation.
Each factor on its own has a small effect, however, with more than one factor combined the effect on graft survival and patient survival can be significant. Graft loss means that the patient has to undergo transplant again, or go back to dialysis or in some cases, graft loss can lead to death.
Level of evidence
This article is a systematic review and meta analysis, hence level of evidence is 1.
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Abdulrahman Ishag
2 years ago
The aim of the study;
—————————-
was to evaluate factors purported to influence the risk of 1-year graft loss in kidney transplant recipients.
The study type ;
———————————–
Systemic review .
The design ;
———————–
The study searched bibliographic databases from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
The literature search identified 19,679 unique citations, of which 2220 citations required full text review; 35 studies ultimately proved eligible.
Inclusion criteria ;
——————————-
1-observational studies of adult ($18 years) kidney recipients receiving their first transplant.
2-studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysi.
The result ;
———————–
1-This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors,
deceased donors, increasing number of HLA mismatches, and recipient age.
2-The study identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease.
3-With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Strengths;
——————————-
1-It is a large-scale, systematic review .
2-Using rigorous meta-analytic methods, the review provides precise measures ,compared with any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies.
3-The use of GRADE methodology enabled us to not only report on the direction and magnitude of the association for each risk factor, but also to transparently report on the certainty of the evidence.
Limitations;
————————–
1-The study included United Network for Organ Sharing (UNOS) registry studies to represent all studies published from individual centers in the United States. By doing so, the quality of this review is dependent upon the quality of the UNOS registry data.
2-potential candidates for transplant may be rejected because of patient factors that were not included. These may include, but not be limited to active infections and combination of older age with constellation of other comorbidities such as obesity, cardiovascular disease, malignancies, and irreversible obstructive or restrictive pulmonary disease .
Conclusion ;
—————————–
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small.
What is the level of evidence provided by this article?
———————————————————————-
Level I
HI Dr Ishag,
Your headings and sub-headings should be in bold or underline. That will make it easy to read.This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Ajay
Last edited 2 years ago by Ajay Kumar Sharma
Mohammed Abdallah
2 years ago
Please summarise this article
Introduction
With expansion of the pool of kidney grafts with the use of use of higher risk donors, graft survival may be changed. So, identification of these risk factors is important
Aim of the study
Assess risk factors for kidney graft survival at 1 year post-transplant
Materials and Methods
The study searched bibliographic databases (2000 -2017) and included observational studies of adult kidney recipients receiving their first transplant, including studies evaluating the asso ciation between any risk factors and 1-year graft loss using multivariable analysis
Results
19,679 citations were identified, of which 35 studies proved eligible
Excluding patients with early graft survival (any study that excluded patients with graft survival less than 1 year)
Six donor characteristics; five were independently associated with 1-year graft loss (donor type, donor quality, donor, donor sex, and donor BMI)
Insignificant association between donor serum creatinine level and the risk of 1-year graft loss
Nine transplant recipient variables were identified, four of the them were significantly associated with 1-year death-censored graft loss (recipient age, pretransplant smoking, pretransplant recipient coronary artery disease, and number of pretransplant years on dialysis)
Discussion
The study identified five risk factors donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age
Limitations of the study
1. studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up were included
2. Results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model
3. potential candidates for transplant may be rejected because of patient factors that were not included
Conclusions
1-year graft survival is predicted by recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches
What is the level of evidence provided by this article?
Level 1 (systemic review and meta-analysis)
HI Dr Abdallah, I could not understand why Cox Regression analysis would be a limitation? Ajay
Last edited 2 years ago by Ajay Kumar Sharma
Huda Al-Taee
2 years ago
Summary:
Aim of the study:
To assess the risk factors for graft survival at 1-year post-transplant.
Methods:
Design: systematic review and meta-analysis
studies (including observational studies) and databases from 2000-2017.
Search methods: d MEDLINE, EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews.
Inclusion Criteria: observational studies of adult (>18 years) kidney recipients receiving their first transplant, including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis. no language or publication status restriction. abstracts are also included.
the risk of bias of individual studies was assessed using the Quality in Prognostic Studies instrument.
Results:
35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
Six factors were associated with graft loss, with a moderate to a high degree of certainty: donor age, extended criteria donors, deceased donors, number of HLA mismatches, recipient age, and delayed graft function as risk factors for 1-year graft loss.
Pooled analyses also excluded any associations of cold ischemia time, recipient race, pretransplant body mass index, diabetes, and hypertension with 1-year graft loss.
Conclusion:
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small.
Strengths:
first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after kidney transplantation.
the review provides precise measures, compared with any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies.
The use of the GRADE methodology enabled the authors to not only report on the direction and magnitude of the association for each risk factor but also to report on the certainty of the evidence transparently.
Limitations:
This meta-analysis included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
Level of Evidence:
Level 1 (systematic review and meta-analysis).
Dear Dr Huda, I could not understand why Cox Regression analysis would be a limitation?This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Last edited 2 years ago by Ajay Kumar Sharma
Mohamed Mohamed
2 years ago
1. Please summarise this article Introduction
With the increasing use of high risk donor in an attempt to expand donors pool, it is important to understand factors associated with a higher risk of graft loss in the 1styear post-TX.
The objective of this study is to assess the predictive power of key risk factors for kidney graft survival at 1 year post-TX. Study design
Search of bibliographic databases from 2000 to 2017, including observational studies that assessed the link between donor, recipient, TX operation, or early postoperative complications, & 1-year death-censored graft loss. Results
35 eligible primary studies were identified, with 20 risk factors subjected to meta-analysis.
6 factors were associated with graft loss (1-year graft loss), with moderate to high degree of certainty:
1. Donor age
2. ECDs
3. Deceased donors
4. Number of HLA mm
5. Recipient age
6. DGF
The analyses excluded (with a high degree of certainty) any associations of the following with 1-year graft loss:
1. CIT
2. Recipient race
3. Pre-transplant BMI
4. Diabetes
5. Hypertension Discussion Main findings Risk factors significantly associated with 1-year graft loss are: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, & recipient age. Additional 5 variables were also identified: donor sex, donor BMI, recipient’s number of years on dialysis, H/O smoking , & CAD.
This study exclude any association of the following with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, & recipient hypertension. Strengths and Limitations
The study is the 1stlarge-scale, systematic review of risk factors for 1-year graft loss after KTX.
Precise measures were reviewed using rigorous
meta-analytic methods.
The use of GRADE methodology allowed report on the direction & magnitude of the association for each risk factor. Limitation:
Assumption that the authors of the primary studies had tested & ensured the proportional hazards assumption necessary for validity of any reported HR; however, the authors of the individual studies
seldom reported on assessing the necessary assumptions of their regression models. So, the statistical analysis for the risk of bias assessment could not be fully informed by meeting the regression model assumptions. ///////////////////////////////// 2. What is the level of evidence provided by this article? Level I
Dear Dr Mohamed, I could not understand why assumptions in performing regression analysis would be a limitation? This study provides levels 2A evidence, please read my response to Dr Ghalia. Ajay
Ø Review to evaluate factors purported to influence the risk of 1-year graft loss in kidney transplant recipients.
Ø Searched databases from 2000 to 2017
Ø 35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
Ø Six factors were associated with graft loss, with moderate to high degree of certainty:
1) donor age (hazard ratio[HR], 1.11 per 10-year increase; 95% confidence interval [95% CI], 1.04 to 1.18)
2) extended criteria donors (HR, 1.35; 95% CI, 1.28 to 1.42)
3) deceased donors (HR, 1.54; 95% CI, 1.32 to 1.82)
4) number of HLA mismatches (HR, 1.08 per one mismatch increase; 95% CI, 1.07 to 1.09)
5) recipient age (HR, 1.17 per 10-year increase; 95% CI, 1.09 to 1.25), and
6) delayed graft function (HR, 1.89; 95% CI, 1.46 to 2.47)
Ø Pooled analyses excluded, any associations of cold ischemia time, recipient race, pre transplant body mass index, diabetes, and hypertension with 1-year graft loss.
Ø limitation of this review is that we included studies identifying risk factors using Cox regression analysis for graft loss at all-time points in follow-up.
Ø Studies varied considerably in the covariates included in their predictive models (studies included 1166 covariates in their regression models). Thus, results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model
Level 2
This meta analysis study evaluating risk factors for 1-Year graft loss after kidney
transplantation as there is expansion of the pool of kidney donors through the use of higher-risk donors, and increased attention to donor management strategies.
The data collected from 2000 to 2017 and included 35 primary observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
They found Six factors were associated with graft loss:
-donor age.
– extended criteria donors
– deceased donors
– number of HLA mismatches
– recipient age
– delayed graft function
Pooled analyses also excluded,
with a high degree of certainty, any associations of cold ischemia time, recipient race, pre-transplant body mass index, diabetes, and hypertension with 1-year graft loss.
Implication for Guidelines
Numerous recipient and donor characteristics increase the risk of graft
loss post-kidney transplantation. All such factors, although may be associated with graft loss beyond chance, may not be clinically important to diminish the magnitude of benefit
attained from transplantation.
Meta analysis,level 2 evidence
it contain 32 study to get the risk factors of one year graft loss, it divided to donor,operation and recipient risk factors
donor in form of age and sex, operation long cold ischemia time and HLA match
recipient factors includes positive DSA,hypertension and diabetes
35 studies from many countries from 2000-2017 to assess risk factors for graft loss over one-year post-transplantation
findings:
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches,and recipient age. We identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease. With high cer- tainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Level of evidence:II as metanalysis
Please summarize this article
This article reviewed 35 studies from many countries from 2000-2017 to assess risk factors for graft loss over one-year post-transplantation. It is a large-scale review using GRADE methodology to report how certain is the evidence.
Donor factors affecting graft loss: donor’s age, donor type (deceased vs living), extended criteria donors were associated with higher graft loss, donor gender, donor’s BMI.
Transplant process factors affecting graft loss: HLA mismatches.
Recipient factors affecting graft loss: recipient’s age, numbers of years on dialysis, smoking, IHD.
Post-transplant complications affecting graft loss: acute rejection and delayed graft function.
Limitations of the study:
1- Inclusion of unpublished data and registry data.
2- The included studies were variable in the co-variates.
3- The nature of the included studies and recipients with many co-morbidities.
4- The study looks only for 1-year graft loss data.
What is the level of evidence provided by this article?
Level IIA
Kidney transplantations have the highest rate of graft survival among all other organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
This review recognized five risk factors, for which there is moderate to high confirmation in the magnitude of correlation with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age. We identified an additional five variables for which, with moderate confirmation, there is an association with 1-year graft loss: donor sex, BMI, recipients duration on dialysis, history of smoking, and CAD. With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increase of cold ischemia time, recipient age, BMI, recipient diabetes, and hypertension.
Cold ischemia time was not found to be associated with 1-year graft loss.
No evidence was found regarding association between donor creatinine and 1-year graft loss.
In summary, this systematic review and meta-analysis identified 10 risk factors for which there is moderate or high certainty in their strength and extent of association.
The factors include recipient age, donor age, ECD, deceased donors, and increasing HLA mismatches.
With high certainty, it is establish that increasing cold ischemia time, recipient BMI, recipient diabetes, and hypertension do not have significant associations with 1-year graft survival.
level 2 article.
Q1- Please summarise this article.
Abstract
With expansion of the pool of kidney grafts, by using nonstandard risk dono , the 1-year graft survival rate is subject to change. This study used to determine the 1-year graft survival rates in the low-risk and high-risk kidney transplant cases.
Design, setting, participants, & measurements: Systematic Review and Meta-Analysis.
Result:
Factors associated with graft loss ( risk factors for 1-year graft loss ) :
1- donor age
2- extended criteria donors
3- , number of HLA mismatches
4- recipient age
5- delayed graft function .
data report no associations of the following with 1-year graft loss.
1) cold ischemia time,
2) recipient race,
3) pretransplant body mass index,
4) diabetes,
5) hypertension.
Conclusions
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor,
HLA mismatch, and delayed graft function all predicted1-year graft survival .The effect of each risk factor is small.
Introduction:
Graft loss results in re start dialysis, re transplantation, or death. Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year deceased graft survival.
With expansion of the pool of kidney grafts, through the use of higher risk donors, then , 1-year graft survival may change therefore useful to identify low-risk and high-risk kidney transplant cases.
Materials and Methods: Systematic Review and Meta-Analysis.
Discussion
Principal Findings
This review identified five risk factors, with moderate to high certainty association with 1-year graft loss:
1) donor age.
2) extended criteria donors.
3) deceased donors.
4) increasing number of HLA mismatches.
5) recipient age.
five additional variables , with moderate certainty, association with 1-year graft loss:
1) donor sex.
2) donorBMI.
3) recipient’s number of years on dialysis.
4) history of smoking.
5) coronary artery disease.
This study found no association of the following variables with 1-year graft loss:
1) Increasing cold ischemia time.
2) recipient age.
3) recipient BMI.
4) Recipient diabetes.
5) recipient hypertension.
Strengths and Limitations
This study is the first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after kidney transplantation.
The use of GRADE methodology enabled us to not only report on the direction and magnitude of the association for each risk factor, but also to trans parently report on the certainty of the evidence.
One limitation of this review is that we included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
By using UNOS registry , the quality of this review is dependent upon the quality of the UNOS registry data.
Conclusion:
This systematic review and meta-analysis identify ten risk factors with moderate or high certainty of association. These factors include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches. With high certainty, this study report that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival.
Q2- What is the level of evidence provided by this article?
This is a Systematic Review and Meta-Analysis study. The Level 01 .
After transplantation, maximizing graft longevity becomes a focus of care. Graft loss results in return to dialysis, retransplantation, or death. Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors . With expansion of the pool of kidney grafts, through the use of higher risk donors, and increased attention to donor management strategies, 1-year graft survival may change.Itis therefore useful to identifylow-risk and high-risk kidney transplant cases.
Prognostic studies can guide clinicians and patients in better understanding factors associated with a
higher risk of graft loss in the first-year post- transplantation. Although formal risk prediction models can inform prognosis, existing models in kidney transplant perform poorly: the discriminatory performance of existing models ranges from 0.54 to 0.72, either below or marginally above the minimal threshold (0.6) for acceptable performance
Discussion
Principal Findings
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age. We identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease. With high cer- tainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Strengths and Limitations
This study is the first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after kidney transplantation. By only reviewing adjusted evidence, users of our estimates can multiply the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss. Using rigorous meta-analytic methods, the review provides precise measures, compared with any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies. The use of GRADE methodology enabled us to not only report on the direction and magnitude of the association for each risk factor, but also to trans- parently report on the certainty of the evidence.
One limitation of this review is that we included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up. By doing so, we assumed that the authors of the primary studies had tested and ensured the proportional hazards assumption necessary for validity of any reported HR. The authors of the individual studies seldom reported on assessing the necessary assumptions of their regression models. As a result, our statistical analysis for the risk of bias assessment could not be fully informed by meeting the regression model assumptions.
In the context of identifying factors that increase the risk of graft loss in the year after transplant, the studies in this review have a fundamental limitation: potential candidates for transplant may be rejected because of patient factors that were not included. The reasons for not recommending transplant in such individuals may be the most powerful determinants of outcome. These may include, but not be limited to active infections and combination of older age with constellation of other comorbidities such as obesity, cardiovascular disease, malignancies, and irreversible ob- structive or restrictive pulmonary disease
that cold ischemia time was not associated with 1-year graft loss. The simplest explanation for this finding is that, indeed, there is no association. Another plausible explanation is that present day use of storage techniques such as machine perfusion and preservation solutions minimize cold ischemia damage to the kidney
Implication for Guidelines
From this review, however, it is evident that numerous recipient and donor characteristics increase the risk of graft loss postkidney transplantation. All such factors, although may be associated with graft loss beyond chance, may not be clinically important to diminish the magnitude of benefit attained from transplantation. This necessitates the need for risk prediction models to guide clinicians in selection of candidates whose risk for graft loss (disadvantaging the societal need for organ donors) may be higher than their risk of mortality on dialysis.
In conclusion, our systematic review and meta-analysis identified ten risk factors for which we have moderate or high certainty in their strength and magnitude of association. These factors include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches. With high certainty, we were able to establish that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival.
Level II
Risk Factors for 1-Year Graft Loss After Kidney
Transplantation
Databases from 2000 to 2017 were searched to measured the association between donor, recipient,the transplant operation , early post-operative complications and 1-year death-censored graft loss.
Donor risk factors:
Donor age /increase graft failure
Donor sex ( female versus male ) / female sex increases the risk of graft failure slightly.
Type of donor ( deceased versus living )/ deceased increases graft failure.
ECD slightly increases graft failure
BMI /higher donor BMI decrease graft failure slightly.
Increase creatinine in donor has no effect on graft failure.
Recipient characteristics:
Age of recipient/ increase 1-year graft loss.
Sex of recipient has no effect on graft loss.
Race of recipient had no effect on graft loss.
BMI of recipient has little or no effect on graft failure.
Dialysis time / prolonged time increases graft failure.
Diabetes/recipient DM has no effect on graft failure.
Transplant operation risk factors:
Cold ischemia time has no effect on graft loss.
HLA mismatch/ one mismatch increase slightly graft loss.
Level of evidence II
Due to the increasing utilization of extended criteria kidney donors, 1 year allograft survival might be potentially changed.
This meta-analysis involved studies conducted between 200 and 2017, to verify one year allograft survival and assess interplaying factors pertinent to the censored survival.
Extended criteria donors:
1)Age more than 60 year
2)
50-59 with 2 out of 3,history of cerebrovascular accident ,Hypertension and creatinine of more 1.5.
Delayed graft function :was tagged as there is allograft dysfunction necessitating HD.
patients with inferior result featured characteristics related to donor, operation and post operative course of allograft function.
Number of HLA mismatchs. was observed as significant factor for 1-year death censored graft loss.On the contrary Cold ischemia time was not recognized as substantial factor influencing outcome.
Recipients associated risk factors:
Pre transplant smoking, ischemic heart disease, years on dialysis and age are associated with lower 1 year death censored allograft loss.
Post transplant complication:
Acute rejection and delayed graft function are featuring higher one year death censored graft loss.
Meta -analysis with level of evidence 1
Long periods of waiting in line are still a reality for many ESKD patients. One of the alternatives for the increase in donated organs was the establishment of extended criteria, but this, together with other factors, has altered 1-year graft survival. So this systematic review and meta-analysis of studies reassess risk factors to inform prognosis, and evaluate models in kidney transplant perform.
Observational studies of adult (> 18 years) kidney recipients receiving were selected their first transplant, including evaluating studies the association between any risk factors and 1-year graft loss using multivariable analysis.
This studied identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, recipient age.
This studied identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease.
Another gain from this study was that this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension
The level of evidence is 01 , because is a Meta analysis
summary ofRisk factors for 1 year graft loss after kidney transplantation:
Graft loss/patient came back to dialysis, re transplantation or death
A systematic review and metanalysis of studies assessing high risk factors for graft loss to improve the ==of potential source of discrepancy between studies.
Data sources:
Med lines embase cohort control for systematic review between the years 2000-2014
Study selection:
Select studies of adult ≥18 years
Kidney recipients
Receiving the first transplant, including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis
Results:
35 eligible studies, review Jneded 18 to have high risk of bias
Risk of bias in the recipient DM and delay graft function showed statistically significant affect estimate in studies at high ==low risk of bias
Discussion:
The review identified five risk factors for which there is moderate to high association with 1-year graft loss risk factors include:
1. Donor age
2. Extended criteria donors
3. Deceased donors
4. Increasing marker of HLA mismatch
5. Recipient age
Moderate risk factors:
1. Donor sex
2. Donor BMI
3. Recipients number of years on dialysis
4. History of smoking
5. History of coronary artery disease
Another varible moderate factors associtted with
1- Tear graft loss :
1-donor sex.
2-donor BMI.
3-recipient number of years on dialysis.
4-history of smoking.
5- history of coronary artery disease.
Study limitation
1-study identify risk factors using cox regression analysis for graft loss at all time point in follow-up.
So our statical analysis for the risk of bias assessment could not be fully informed by meeting the regression model assumption.
2-fundamental limitation potential candidate for transplant may be reject because of patient factors.
Exclusion criteria for study
Recipient sex
Race
BMI
DM
HTN
Donor creatinine
Cold ischemia time
Extended criteria donor as arisk factor for 1 year graft loss
Implication for guidelines
Need for risk prediction models to quide clinican in selection of candidates who risk for graft loss
Ten risk factor concluded in this study:
1- Recipient age.
2- Donor age.
3- Extended criteria donor.
4- Deceased donor.
5- Increasing number of HLA mismatch .
In the future development of risk prediction models, may improve discrimination such models in turn may guide the judgment clinicians need to make in the highest risk of recipient and donor.
evidence level 2
This is a meta-analysis included 35 studies taken after reviewing 2220 articles, analysis the causes of graft failure with in first year post-transplantation. They identified five risk factors like EDC, age of donor, DCD, degree of mismatch, BMI>30, prolonged history of dialysis.
level II
1. Please summarise this article
This is a meta-analysis of the factors that influence the risk of graft loss in the first year post kidney transplant. It included 35 studies chosen after reviewing 2220 articles. The significant factors associated were only 6 including the donor age, extended criteria donors, deceased donors, number of HLA mismatches, recipient age and delayed graft function. On the other hand, cold ischemia time, recipient race, prtransplant body mass index, diabetes, and hypertension are not associated with one year graft loss.
Strong points:
1- the first large-scale, systematic review of studies addressing this subject.
2- Used rigorous meta-analytic methods to provides precise measures
3- use of GRADE methodology enabled the certainty of the evidence.
Limitation:
1- It included studies which used Cox regression analysis for graft loss at all-time points in follow-up. So, the risk of bias assessment is present.
2- This analysis depended on the United Net-work for Organ Sharing(UNOS) registry studies so, the quality of this review is dependent upon the quality of the UNOS registry data.
3- The results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model or patient factors that were not included.
2. What is the level of evidence provided by this article?
Level IIA
Level II; Systematic Review and Meta-Analysis
Systematic Review and Meta-Analysis to study Risk Factors for 1-Year Graft Loss After Kidney Transplantation
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age.
An additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of
smoking, and coronary artery disease.
the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
Discussion
Principal Findings
This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age. We identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease. With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
cold ischemia time was not associated with 1-year graft loss.
no evidence of an association between donor creatinine and 1-year graft loss.
In conclusion, our systematic review and meta-analysis identified ten risk factors for which we have moderate or high certainty in their strength and magnitude of association.
These factors include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches.
With high certainty, we were able to establish that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival.
level 2
The current article describes the systematic review and metanalysis of all post transplant patients to assess the risk factors associated with graft loss.. This was a database search from 2000 to 2017….This analysis included all observational studies only.. There were no RCT included in this meta analysis…
35 eligible primary studies have been included in the analysis and few factors were found to be associated with graft loss of moderate to severe intensity….
Meta analysis of donor factors: 6 donor factors were studied and 5 were found to be associated with graft loss. They are advanced donor age, deceased donors as compared to live donors, extended criteria donors as compared to standard criteria donor, donor BMI (higher BMI associated with higher risk) and female donors (due to low nephron mass). Donor creatinine at the time of transplant did not show association with graft loss at 1 year..
Meta analysis of transplant process: Number of HLA mismatches was associated with graft loss at 1 year while the cold ischemia time did not have an association
Meta analysis of recipient factors: All the studies included 9 variables out of which 4 were associated with 1 year graft loss…Recipient’s age, pre transplant smoking, pre transplant coronary artery disease and number of years on dialysis are the positive factors, while other factors like recipient co morbid or gender with graft loss
Meta analysis of post transplant complications: The literature reviewed also identified delayed graft function and Acute rejection as post transplant risk factors associated with graft loss at 1 year..
This is the first large scale systematic review of the observational studies to assess the risk factors for graft loss at 1 year….They also used the GRADE technology to ascertain the transparency of the risk associated with the end point….the limitation of the analysis is the use of only observational studies and not RCT…
The analysis of the risk factors paves way to develop a risk prediction model tool for assessment of graft loss in the future
The level of evidence is 2A (systematic review but including only observational studies)
The current review is a systematic analysis and meta analysis to assess the risk factors for the graft loss within 1 year post transplantation. the database was searched from 2000 to 2017 and all the observational studies that evaluated association between donor, recipient, early post transplant operation and 1 year death censored graft loss were included.
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLAmismatch, anddelayed graft function all predicted1-year graft survival.
STRENGTHS
LIMITATIONS
Level 2 evidence
Objective :
The objective of the study was to evaluate factors purported to influence the risk of 1-
year graft loss in kidney transplant recipients.
Introduction:
In patients with ESKD, transplant improves quality of life and survival, however, because
of the high demand and limited resources. Patient wait longtime on hemodialysis.
Kidney transplant recipients have the highest rate of graft survival among all organs
transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
. With expansion of the pool of kidney grafts, with higher risk donors, and increased
attention to donor management strategies, 1-year graft survival may change. It is
therefore useful to identify low-risk and high-risk kidney transplant case.
Materials and Methods Data Sources and Searches:
A search of bibliographic databases in February of 2017. Specifically, MEDLINE,
EMBASE, Cochrane central register for controlled trials, and Cochrane database for
systematic reviews for citations between the years 2000–2017.
Study Selection and Data Extraction:
Selected observational studies of adult (18 years) kidney recipients receiving their first
transplant, including studies evaluating the association between any risk factors and 1-
year graft loss using multivariable analysis.
Results Study Selection and Characteristics:
35 studies ultimately proved eligible.
The individual studies included patients from Canada, Denmark, Germany, Ireland, Italy,
Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and Unit states.
Risk of Bias of Individual Studies:
Of the 35 eligible studies, reviewers judged 18 to have high risk of bias.
Among the included studies, the authors included an average of 11 variables.
Across the many risk factors included in this review, only the subgroup analyses for risk
of bias in recipient diabetes and delayed graft function showed statistically significant
different effect estimates in studies at high versus low risk.
Meta-Analyses of Donor Factors:
Six donor characteristics being assessed; five were independently associated with 1-
year graft loss in the original studies and proved predictive in the met analysis.
Donor type, donor quality of deceased donor, donor age, donor sex and donor body
mass index .
Meta-Analyses of Transplant Process Factors:
The number of HLA mismatches was the only risk factor, for which we observed an
association beyond chance, with 1-year death-censored graft loss.
No significant association between cold ischemia time and graft loss.
Meta-Analyses of Recipient Factors:
Nine transplant recipient variables identified.
Four of the nine were significantly associated with 1-year death-censored graft loss:
recipient age, Pretransplant smoking, Pretransplant recipient coronary artery diseases,
and number of Pretransplant years on dialysis.
No a statistically significant association for recipient sex, race, BMI, hypertension, or
diabetes with 1-year graft loss.
Meta-Analyses of Post-Transplant Complications:
Identified delayed graft function and acute rejection as early post-transplant
complications associated with death-censored graft loss.
For both, we observed a statistically significant association with 1- year graft loss.
Discussion:
Principal Findings:
This review identified five risk factors, for which there is :
Moderate to high certainty in the magnitude of association with 1-year graft loss: donor
age, extended criteria donors, deceased donors, increasing number of HLA mismatches,
and recipient age.
With moderate certainty, there is an association with 1-year graft loss:
Donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and
coronary artery disease.
With high certainty, the findings of this study exclude any association of the following
variables with 1-year graft loss:
Increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and
recipient hypertension.
Strengths:
Meta-analytic methods, the review provides precise measures, compared with any
individual study.
Limitations:
The risk of bias assessment could not be fully informed by meeting the regression model
assumptions.
Large registries i.e. UNOS used for data collection in USA.
Potential candidates for transplant may be rejected because of patient factors that were
not included.
Implication for Guidelines:
The optimal utilization of the factors identified as risk factors, in development of future
risk prediction models, may improve discrimination and calibration.
Such models in turn may guide the judgment clinicians need to make on the highest risk
recipient and donor.
Level of evidence 2a.
#Please summarise this article
# The objective:
The objective of the study was to evaluate factors purported to influence the risk of 1-year graft loss in kidney transplant recipients.
#Introduction:
*After transplantation, maximizing graft longevity becomes a focus of care. Graft loss results in return to dialysis, re-transplantation, or death.
* With expansion of the pool of kidney grafts, through the use of higher risk donors, and increased attention to donor management strategies, 1-year graft survival may change. It is therefore useful to identify low-risk and high-risk kidney transplant cases.
# Design, setting, participants, & measurements
They searched bibliographic databases from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
# Results
*They identified 35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
* Six factors were associated with graft loss, with moderate to high degree of certainty: donor age, 1.11 per 10-year increase; 95% confidence interval [95% CI], 1.04 to 1.18), extended criteria donors (HR, 1.35; 95%CI, 1.28 to 1.42), deceased donors (HR, 1.54; 95% CI, 1.32 to 1.82), number of HLA mismatches (HR, 1.08 per one mismatch increase; 95%CI, 1.07 to 1.09), recipient age (HR, 1.17 per 10-year increase; 95%CI, 1.09 to 1.25), and delayed graft function (HR, 1.89; 95% CI, 1.46 to 2.47) as risk factors for 1-year graft loss.
* Pooled analyses also excluded, with a high degree of certainty, any associations of cold ischemia time, recipient race, pretransplant body mass index, diabetes, and hypertension with 1-year graft loss.
# Strengths and Limitations
*It is the first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss PKT.
*The estimates can multiply the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss.
* Using rigorous meta-analytic methods, it provides precise measures, Vs any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies.
*The use of GRADE methodology helps to report the direction and magnitude of the association for each risk factor and transparently report on the certainty of the evidence.
*The limitation is that included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up. By doing so, that the authors of the primary studies had tested and ensured the proportional hazards assumption necessary for validity of any reported HR.
* The quality of this review is dependent upon the quality of the UNOS registry data.
*The studies have a fundamental limitation: potential candidates
for transplant may be rejected because of patient factors that were not included.
# Conclusions
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted1-year graft survival. The effect of each risk factor is small.
# What is the level of evidence provided by this article?
*Level A 2
Risk Factors for 1-Year Graft Loss After Kidney
Transplantation
________________
Introduction
▪︎Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors. With expansion of the pool of kidney grafts, 1-year graft survival may change.
Prognostic studies can guide clinicians and patients in better understanding factors associated with a higher risk of graft loss in the first-year posttransplantation. Although formal risk prediction models can inform prognosis, existing models in kidney transplant perform poorly.
▪︎The limited performance of current models may result from including risk factors useful in one cohort but not in others.
▪︎The aim of this review:
To assess the predictive power of key risk factors for kidney graft survival at 1 year post-transplant
◇ Design, setting, participants, & measurements:
▪︎ Bibliographic databases were searched from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
◇ Results:
▪︎35 eligible primary studies, with 20 risk factors amenable to meta-analysis were identified. ▪︎Six factors were associated with graft loss, with moderate to high degree of certainty: donor age, extended criteria donors deceased donors, number of HLA mismatches, recipient age, and delayed graft
function as risk factors for 1-year graft loss.
▪︎Pooled analyses also excluded, with a high degree of certainty, any associations of cold ischemia time, recipient race, pre-transplant body mass index, diabetes, and hypertension with 1-year graft loss.
◇ Strengths of the study:
1. The first large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after renal transplantation.
2. By only reviewing adjusted evidence, users of this estimates can multiply the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss.
3. Provides precise measures, compared with any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies.
4.The use of GRADE methodology enabled the authors to not only report on the direction and magnitude of the association for each risk factor, but also to transparently report on the certainty of the evidence.
Limitations
1. Included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
2.The quality of this review is dependent upon the quality of the UNOS registry data.
3. Results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model.
4. In the context of identifying factors that increase the risk of graft loss in the year after transplant, the studies in this review have a fundamental limitation: potential candidates
for transplant may be rejected because of patient factors that were not included. The reasons for not recommending
transplant in such individuals may be the most powerful
determinants of outcome.
Implication for Guidelines
▪︎From this review, however, it is evident that numerous recipient and donor characteristics increase the risk of graft
loss postkidney transplantation. All such factors, although
may be associated with graft loss beyond chance, may not be clinically important to diminish the magnitude of benefit
attained from transplantation. This necessitates the need
for risk prediction models to guide clinicians in selection of candidates whose risk for graft loss may be higher than their risk of mortality on dialysis.
▪︎Risk associations generated from this
review may inspire or provide the foundational information necessary for development of a risk prediction model.
Conclusion:
▪︎This systematic review and meta-analysis
identified ten risk factors with moderate or high
certainty in their strength and magnitude of association. These
factors include recipient age, donor age, extended criteriadonors, deceased donors, and increasing number of HLA mismatches.
▪︎With high certainty, it was established
that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large
associations with 1-year graft survival.
The paper evaluated 35 studies from various countries to assess influence of published risk factors over 1-year graft loss in KTR. However the paper included unpublished data from clinical experts.
Donor Factors:
Transplant factors:
Recipient factors:
Post-transplant risk factors
AR and DGF – moderate certainty.
A year graft loss post kidney transplant depends on donor age, donor type, donor quality, HLA mismatch, recipient age, delayed graft function as well as donor BMI and gender, and recipient coronary artery disease, smoking and dialysis vintage.
Level of evidence: level 2A
Summary:
Introduction:
Graft survival in kidney transplant is important to ensure that patients do not return to dialysis and do not need another kidney or to avoid re-transplant. Kidney transplantation has remained the highest graft survival when compared with other organs. With studies and investigations, clinicians will try to better understand the possible risk factors that can contribute to graft loss.
How the study was conducted?
Information was gathered from Cochrane central register for control trials and the Cochrane database between the period of 200-2017.
Studies evaluated 18 kidney recipients for their first transplant and evaluated the association between the risk factors and the possible 1-year graft loss.
Quality in prognostic studies instrument was used to assess the individual risk bias and the bias risk was classified as low or high.
The investigators applied the grading recommendations assessment development and evaluation (GRADE) assessment in this study.
What was the result of the study?
There were 19679 citations that were identified and 35 of them proved eligible.
The six factors identified were the donor age, extended criteria donor, deceased donors, number of HLA mismatch, Recipient age and delayed graft function, and five variables associated with 1-year graft loss were donor sex, done BMI, the years on dialysis, smoking, and coronary disease.
There was no significant association between the donor serum creatinine level and the possible risk factor of 1-year graft loss.
The study also excluded any association of the following with 1-year graft loss which was the cold ischemic time, the age of the recipient, the BMI of the recipient, and if the recipient has DM and HTN.
Study limitation:
The limitation of the study was that the study identifies risk factors using COX regression analysis for graft loss at the time points in follow-up were included.
The potential candidates for transplant may be rejected due to patient factors not being included.
The quality of the review was dependent on UNOS registry studies.
Studies variations in their predictive models.
Study strength:
The use of the GRADE system
There was a large scale that addressed the possible risk factors associated with the 1-year graft loss.
The use of vigorous meta-analytic methods.
Conclusion:
The study conducted has identified the possible risk factors that can affect the 1-year graft survival after kidney transplantation. Recognizing these risk factors will help physicians to make better decisions as to patient selection.
Summary of the article
Risk Factors for 1-Year Graft Loss After Kidney Transplantation
This is a retrospective study, analyzed controlled trials and systematic reviews for citations between the years 2000–2017, looking for risk factors of graft loss 1-year after kidney transplantation.
Study’s results and outcome:
1. The number of HLA mismatches was the only risk factor, for which there was an observed association beyond chance, with 1-year death-censored graft loss.
2. There was no statistically significant association between donor serum creatinine level and the risk of 1-year graft loss.
3. There was no significant association between cold ischemia time and graft loss.
4. The review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss:
· The donor’s age.
· Extended criteria donors.
· Deceased donors.
· Increasing number of HLA mismatches.
· The recipient’s age.
5. The study identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss:
· Donor sex.
· Donor BMI.
· Recipient’s number of years on dialysis.
· History of smoking.
· History of coronary artery disease.
6. With high certainty, the study’s findings exclude any association of the following variables with 1-year graft loss:
· Increasing cold ischemia time.
· Recipient’s age.
· Recipient’s BMI.
· Recipient’s diabetes.
· Recipient’s hypertension.
The surprise of this study; to find no evidence of an association between donor creatinine and 1-year graft loss. The explanation for this surprise is as follows:
· The inclusion of patient mortality may explain the lack of association between donor creatinine and mortality (it is possible that worse functioning kidneys would not be associated with patient mortality because of the availability of kidney replacement therapies in the event of graft failure).
· Possibly, donors with high creatinine were not selected for transplantation, thus eliminating any association beyond chance.
· The association between donor creatinine and 1-year graft loss is partially captured by the significant association between extended criteria donor as a risk factor for 1-year graft loss.
Conclusion: The followings predicted 1-year graft survival: recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function.
What is the level of evidence provided by this article
This is a retrospective study.
Level of evidence grade 3.
The provided article is a meta-analysis with level of evidence II
Introduction
Maximizing graft longevity is the primary goal of therapy following kidney transplantation. Determining low-risk and high-risk transplant patients is crucial. There are models that help predict graft failure one year after transplantation, but their effectiveness is limited since risk variables vary.
To help construct a prediction model that would more accurately assess the significance of significant risk factors for kidney graft survival at one year following transplant, a meta analysis and systematic review were conducted.
Methodology
For citations between 2000 and 2017, the data sources were MEDLINE, EMBASE, the Cochrane central register for controlled trials, and the Cochrane database for systematic reviews.Using the Quality in Prognostic Studies tool, the risk bias for each study was evaluated.
Results
19,679 citations were retrieved in the literature search, out of which 2220 needed a full text review and 35 studies qualified. Patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Portugal, Spain, South Korea, Taiwan, the United Kingdom, and the United States participated in the investigations.In the original investigations, five of the six donor characteristics—donor type, donor quality, donor age, donor sex, and donor body mass index—were found to be independently related to graft loss at one year.
Discussion
Five risk factors were shown to be connected to 1-year graft loss: recipient age, increasing number of HLA mismatches, extended criteria donors, and donor age. Donor sex, donor BMI, the recipient’s number of years on dialysis, history of smoking, and coronary artery disease were the factors linked to 1-year graft loss.
The review did not find any correlation between 1-year graft failure and increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, or recipient hypertension.
Strengths and weaknesses
The risk variables for graft loss after kidney transplantation after one year have not previously been the subject of a large-scale, systematic review like this one. It was possible to report on the strength and direction of associations for each risk factor thanks to the GRADE methodology.
Its scope was constrained by the use of Cox regression analysis, which presupposed that the primary study authors had verified and evaluated the proportional hazards assumption required for the accuracy of any stated hazard ratios. Another drawback was the possibility that patients’ variables would cause transplant candidates to be passed up.
Conclusion
This review has demonstrated that a number of recipient and donor variables raise the possibility of graft loss following transplantation. To assist clinicians in choosing transplant patients, it is critical to anticipate the probability of graft loss.
Age of recipient, age of donor, donors that meet extended criteria requirements, deceased donors, and an increasing incidence of HLA mismatches are among the risk factors noted.
According to the study, there is no stronger correlation between recipient BMI, recipient diabetes, or recipient hypertension and 1-year graft survival with the increase in cold ischemia time.
INTRODUCTION
· Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors
· After expansion of the pool of kidney grafts, 1-year graft survival needs reevaluation
· This is a review to assess the predictive power of key risk factors for kidney graft survival at 1-year post-transplant
Materials and Methods
· Data Sources and Searches: MEDLINE, EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations between the years 2000–2017
· Study Selection and Data Extraction: observational studies of adult (> or18 years) kidney recipients receiving their first transplant
· Data Synthesis and Statistical Analyses: meta-analysis for any risk factor evaluated in two or more studies, was conducted.
– This review addressed two possible subgroup analyses: risk of bias and outcome definition
Results
· Study Selection and Characteristics: 35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
· Risk of Bias of Individual Studies: 18 of the 35 eligible studies, had high risk of bias, most commonly because of limitations in statistical analysis and reporting
· Meta-Analyses of Donor Factors: No statistically significant association between donor serum creatinine level and the risk of 1-year graft loss
· Meta-Analyses of Transplant Process Factors: The number of HLA mismatches was the only risk factor with 1-year death-censored graft loss
· Meta-Analyses of Recipient Factors: Four of the nine transplant recipient variables were significantly associated with 1-year death-censored graft loss: recipient age, pretransplant smoking, pretransplant recipient coronary artery disease, and number of pretransplant years on dialysis
· Meta-Analyses of Post-Transplant Complications: significant association with 1- year graft loss: delayed graft function and acute rejection
Discussion
· Five risk factors were identified to be associated with 1-year graft loss: 1) donor age 2) extended criteria donors 3) deceased donors 4) increasing number of HLA mismatches 5) recipient age.
· Five variables were associated with 1-year graft loss: 1) donor sex 2) donor BMI 3) recipient’s number of years on dialysis 4) history of smoking 5) coronary artery disease
· Variables not associated with 1-year graft loss: 1) increasing cold ischemia time 2) recipient age 3) recipient BMI 4) recipient diabetes 5) recipient hypertension
Strengths of the study:
· first large, systematic review of studies of risk factors for 1-year graft loss after kidney transplantation
· Using rigorous meta-analytic methods, the review provides precise measures, for the association of each risk factor and graft loss, informed by observational cohort studies
· The use of GRADE methodology
Limitations of the study:
· The author included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up
· Quality of this review is dependent upon the quality of the UNOS registry data only
· The effect of a particular risk factor might differ depending on which variables were included in a particular model
What is the level of evidence provided by this article?
Prospective cohort study, evidence 2
Many patients will have long waitting list because of limited kidneys
● kidney recipients have the highest rate of graft survival among all organs transplanted 92% 1-year graft survival for kidneys transplanted from deceased donors
● studies included patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and United States.
● All studies defined extended criteria donors as .60 years of age or age 50–59 years with two of three associated risk factors: history of cerebrovascular accident, hypertension, or serum creatinine .1.5 mg/dl
● delayed graft function as the need for dialysis within the first week post-transplant.
● five risk factors have moderate to high certainty association with 1-year graft loss: ** donor age
Graft longevity becomes a care focus, as graft loss results in significant morbidity and mortality. Graft survival is subject to changes, especially with the increasing use of marginal donors.
The objective of our study:
To evaluate factors influencing the risk of 1-year graft loss in kidney transplant recipients.
Materials and Methods:
Search in databases from 2000 to 2017 and included:
Observational studies of adult KTR of their first transplant
That measure the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss using multivariable analysis.
The risk of bias was assessed using the Quality in Prognostic Studies instrument.
Results:
35 studies identified eligible primary studies. 20 risk factors amenable to meta-analysis.
Six factors were associated with graft loss, with a moderate to a high degree of certainty:
-Donor age HR1.11 per 10-year increase;
-Extended criteria donors HR, 1.35.
-Deceased donors HR, 1.54.
-Number of HLA mismatches HR, 1.08 per one mismatch increase.
-Recipient age HR, 1.17 per 10-year increase
-Delayed graft function HR, 1.89
Identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss:
Donor sex
Donor BMI
Pre-transplant smoking HR, 1.59 moderate certainty due to serious imprecision.
Pre-transplant recipient CAD HR, 1.15; moderate certainty due to serious indirectness.
The number of pre-transplant years on dialysis HR, 1.03 per 1-year, increases moderate certainty due to serious risk of bias.
Pooled analyses also excluded with a high degree of certainty, any associations with 1-year graft loss.:
-Cold ischemia time
-Recipient race
-Pre-transplant BMI
-Diabetes.
-Hypertension.
Conclusions:
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted1-year graft survival. The effect of each risk factor is small
Strengths:
-a large-scale, systematic review of studies that have conducted adjusted analyses addressing risk factors for 1-year graft loss after KT.
– The review provides precise measures compared with any individual study.
– The use of GRADE methodology enabled us to report on the certainty of the evidence
Limitations:
-It is limited by studies using Cox regression analysis for graft loss at all times in follow-up. Therefore, we assumed
that the authors had tested and ensured the hazards assumption necessary for the validity of any reported HR.
– Studies varied in the covariates included. Thus, results are vulnerable to the possibility that the effect of a particular risk factor
might differ depending on which variables were included in a particular model.
Level of evidence: 2a
Several recipient and donor factors increase the risk of graft loss, theses factors may not be clinically important to avoid the benefit of transplantation, so determining the factors associated with graft loss is important to improve graft outcome.
Risk prediction models are needed to guide the selection of candidates whose risk of graft loss is higher than the risk of mortality on dialysis.
This meta analysis aims to assess the predictive power of risk factors for graft survival at one year.
The authors searched bibliographic databases between 2000 to 2017.
It included observational studies, 35 eligible studies were included and meta analysis for any risk factor evaluated in 2 or more studies.
It identified 5 risk factors with high certainty of association with one year graft loss, donor age, extended criteria donor, deceased donor, increased number of HLA mismatches and recipient age.
It showed 5 risk factors with moderate certainty of association, donor rsex, donor BMI, numbers of years the recipient remained on dialysis, history of smoking and coronary artery disease
There was no association between one year graft survival and prolonged cold ischemia time, recipient age, recipient BMI, recipient DM and recipient HTN.
Strengths:
Large scale systemic review.
The estimates in the study can be multiplied by HR of multiple risk factors to get the combined effect on the risk of 1-year graft loss.
Provided precise measures for the association of each risk factor and graft loss informed by observational cohort studies.
Used GRADE methodology which allowed assessing the magnitude of the association of each risk factor and allowed reporting the certainty of the evidence.
Limitations:
Included studies that identified risk factors using cox regression analysis for graft loss at all time points in follow up, so the statistical analysis of risk of bias assessment was not fully informed by meeting regression model assumptions.
Included UNOS registry studies, so quality of the review is dependent on quality of UNOS registry data which is characterized by limited control over data collection compared to single and multicentered observational studies.
Studies included have different covariates so the effect of particular risk factor may differ according to the variable included in a certain model.
Studies included have a limitation as potential recipients may be rejected because of patient factors that were not included and these factors may be determinant of the outcome.
Level of evidence: 2a (meta analysis of observational cohort studies, no RCT were included)
Please summarise this article
The purpose of this study was to evaluate the risk factors of graft loss at 1 year post kidney transplant.
Methodology
Data base from 2000-2017 was searched and it included observational studies . these t measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
Results and conclusions
35 studies- 20 risk factors amenable to meta analysis.
6 factors associated with graft loss-
Donor age
ECD
Number of HLA mismatches
Recipient age
Delayed graft function
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival.
The effect of each risk factor is small.
What is the level of evidence provided by this article?
Level 2a
Introduction
After kidney transplantation, the focus of care is mainly on maximizing graft longevity. It is therefore important to identify low-risk and high-risk transplant cases. There are existing models that assist in prognosticating graft loss 1 year post transplantation, but they have limited performance as risk factors are varied.
The meta analysis and systemic review was performed to guide the development of a prediction model that would better asses the power of key risk factors for kidney graft survival at 1 year post transplant.
Methodology
The data sources were the MEDLINE, EMBASE, Cochrane central register for controlled trials and the Cochrane database for systematic reviews for citations between 2000 and 2017.
The risk bias for individual studies was assessed using the Quality in Prognostic Studies instrument.
Results
The literature search found 19,679 citations out of which 2220 required a full text review, 35 studies proved eligible. The studies included patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom and the United States.
The review assessed six donor characteristics, five were independently associated with 1-year graft loss in the original studies: donor type, donor quality, donor age, donor sex, donor body mass index.
The meta-analyses of transplant process factors showed that the number of HLA mismatch was the only risk factor that was associated with a 1 year death censored graft loss. There was no significant association between cold ischemia time and graft loss.
The meta-analyses of recipient factors identified factors that had been investigated in two or more of the primary studies. They were significantly associated with 1-year-death-censored graft loss and included recipient age, pretransplant smoking, pretransplant recipient coronary artery disease, and number of pretransplant years on dialysis. No statistical significant association was observed for recipient sex, race, BMI, hypertension or diabetes with 1-year graft loss.
Delayed graft function and acute rejection were the early post-transplant complications associated with death-censored graft loss.
Discussion
The review identified five risk factors that were associated with 1-year graft loss: donor age, extended criteria donors, increasing number of HLA mismatches and recipient age. The variables associated with 1-year graft loss included donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking and coronary artery disease.
The review excluded any association of increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes and recipient hypertension with 1-year graft loss.
Strengths and limitations
This study is the first large-scale, systematic review addressing risk factors for 1-year graft loss after kidney transplantation. The use of GRADE methodology enabled to report on magnitude and direction of association for each risk factor.
It was limited by the use of Cox regression analysis, which assumed that the authors of the primary studies had tested and ensured the proportional hazards assumption necessary for validity of any reported hazard ratios. Another limitation was that the potential candidates for transplant may be rejected because of patient factors that were not included.
Conclusion
From this review, it is shown that many recipient and donor characteristics increase the risk of graft loss after transplantation. It is important to predict the risk of graft loss in order to guide clinicians in selection of candidates for transplantation.
The risk factors identified include: recipient age, donor age, extended criteria donors, deceased donors and increasing number of HLA mismatches.
The study also established that increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have an increased association with 1-year graft survival.
Level Of Evidence
This is a meta analysis so the level of evidence is 1
Summary
This is a review article of many observational studies through database search between 2000-2007 and they include only 35 studies from the search of > 19000 studies addressing the risk factors that might affect the 1-year graft survival (its prognostic type of study) that can help and guide us to identify short and long-term risk factors in the first year after transplantation that can impact the graft survival This review addressed two possible subgroup analyses: risk of bias and outcome definition.
Method
Materials and setting
Data sources
Systemic review through the Embase, and Midline search from controlled registered trials, Cochrane, search for systemic reviews including citation between 2000-2007
Selection criteria include all observational studies that address the risk factor got graft loss after 1 year from transplantation for adults > 18 years old including cited reviews and unpublished studies, they did not restrict to language in their search to asses risk selections bias between studies they use quality in prognostic studies tools also they report the statistical heterogenicity over visual inspection of forest plots, observing for the reliability of point estimates and the range of overlap in confidence intervals.
There is heterogenicity in trails design and selections criteria, immunosuppression protocols diverse populations
Risk of bias
Out of 35 eligible studies still, 18 studies have a high risk of bias due to imitation in statistical analysis
They identify 20 risk factors in relation to the donor like donor age, ECD, BMI Deceased vs living donor, recipients’ risks like age and comorbid, immunological risks like numbers of HLA mismatches, complications like DGF,
Results
in this review, they reported five risk factors associated with moderate to high certainty in the value of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, an increasing number of HLA mismatches,and recipient age
10 risk factors are associated with a high to moderate high of graft concerning death in the first year after transplantation including donor age and ECD, DD also old recipient, numbers of HLA mismatches, and DGF as a complication. no evidence of an association between donor creatinine and 1-year graft loss. This can be explained in part that donors with high creatinine were excluded from the donation also the inclusion of patient mortality may explain the lack of association between donor creatinine and mortality. However, in one report they acknowledged that donor eGFR .60 ml/min per kilogram is associated with a lower risk of graft loss at 1-year post kidney transplantation
Strength of the study
Large sample size with a diverse population
A systemic review of only adjusted indications for the predictive risk factors by using hard data analysis methods to adjust for risks of bias including the use of GRADE methodology
Limitations
There is heterogenicity in trails design and selections criteria, risk stratifications, short fu for certain risk factors, and outcome
Bias with risk prediction models and moderate to the serious inconsistency in the quality of evidence
1. In this review, a short follow-up time of 1 year may explain the lack of association beyond the chance for recipient sex and graft loss
2. Failed association between race and graft loss can be explained by the falling racial difference in kidney transplantation.
3. discrimination and standardization of Cox regression analysis for graft loss at all time points in follow-up.
4 Including large registry data including UNOS so the quality of the study may depend on the quality of registry data.
however, this review indicates the need for future research with better design of risk prediction models including cardiovascular disease with longer follow-up to guide clinicians in their selection of candidates whose risk for graft loss may be higher than their risk of mortality on dialysis
review from observational cohort studies including heterogenous, unpublished studies despite the systematic review, and including big registry data that might mask the quality of evidence still can not be of level l, no single RCT included.
level 2 A
● Many patients will have long waitting list because of limited kidneys
● kidney recipients have the highest rate of graft survival among all organs transplanted 92% 1-year graft survival for kidneys transplanted from deceased donors
● studies included patients from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and United States.
● All studies defined extended criteria donors as .60 years of age or age 50–59 years with two of three associated risk factors: history of cerebrovascular accident, hypertension, or serum creatinine .1.5 mg/dl
● delayed graft function as the need for dialysis within the first week post-transplant.
● five risk factors have moderate to high certainty association with 1-year graft loss: ** donor age
**extended criteria donors
** deceased donors
** increasing number of HLA mismatches,
** recipient age
● An additional five variables have moderate certainty association with 1-year graft loss:
** donor sex
** donor BMI
** recipient’s number of years on dialysis,
** history of smoking
** coronary artery disease
● With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss:
** increasing cold ischemia time
** recipient age
** recipient BMI
** recipient diabetes
** recipient hypertension.
● limitation
** The authors of the individual studies
seldom reported on assessing the necessary assumptions of their regression models.
** statistical analysis for the risk of bias assessment could not be fully informed by
meeting the regression model assumptions
** the quality of this review is dependent upon the quality of the UNOS registry data. ** more likely to ensure data quality before analysis of risk factors
** results are vulnerable to the possibility that the effect of a particular risk factor
might differ depending on which variables were included in a particular model.
** studies in this review have a fundamental limitation:
** potential candidates for transplant may be rejected because of patient factors
that were not included.
● present storage techniques such as machine perfusion and preservation solutions minimize cold ischemia damage to the kidney
Level :2
This article is systemic review and meta analysis done between 2000 to 2017 address risk factors of kidney loss and compression between recipient and donor graft survival.
Kidney transplant is a successful operation in compare to all organ transplant which reach to 92%. The fate of kidney graft loss is dialysis or retransplant and death.
There’s 5 donor risk factors associated with graft loss is age/ sex (female) probably increase risk of graft loss / BMI more than 30, increase risk of graft loss and delay graft function required dialysis within one week post transplant. Extended donor criteria is age more than 60 years or age between 50 to 59 years associated with 2 to 3 comorbidites like cerebrovascular accidents or diabetes and hypertension or creatinine level more than 1.5 mg/ dl. All this factors contribute for graft loss.
Transplant process factors// This study shows no significant increase of cold ischemic time long in one hour and graft loss despite donor age and sex / donor type and donor cause of death and history of early graft rejection and evidence of cardiovascular disease and donor HLA mismatch. The number of HLA mismatch carriers high risk of graft loss.
Also type of donor whether living or deceased has role in graft loss since deceased donor increase risk of graft loss.
Recipient risk factors:
This study address nine factors four of them are highly risk of graft loss in one year. There are recipient age / number of pre transplant dialysis duration and pretransplant smoking and pretransplant coronary arteries disease. However pretransplant smooking and coronary arteries disease contribute for graft loss.
There’s no significant associated between sex and race of recipient and BMI and presence of hypertension and diabetes in graft loss within one year.
Pist transplant complications:
This study also address the associated with delay graft function and acute kidney rejection. However both increase rate of graft failure.
Finally it’s large systemic review and meta analysis identify ten risk factors for evaluate graft function loss in one year post transplant age, sex, race of donor and recipient , duration of dialysis pre transplant and number of HLA mismatch and type of donor and extended criteria of donor. increase cold ischemic time.
Q2: level 2
Please summarise this article
-Graft loss results in return to dialysis, retransplantation, or death.
-Kidney transplant recipients have the highest rate of graft survival among all organs transplanted: 92% 1-year graft survival for kidneys transplanted from deceased donors .
– It is bibliographic databases from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss
-This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age.
-Other variables for which, with moderate certainty, there is
an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease.
-The increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension do not have large associations with 1-year graft survival.
Strengths and Limitations
–Strengths:This study is the first large-scale, systematic review of
studies that have conducted adjusted analyses addressing
risk factors for 1-year graft loss after kidney transplantation.
-The use of GRADE methodology enabled them to not only report on the direction and magnitude ofthe association for each risk factor, but also to transparently report on the certainty of the evidence.
–Limitations :they included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
-The quality of this review is dependent upon the quality of the
UNOS registry data.
What is the level of evidence provided by this article?
Level 1
Dear Dr Reem,
I like your analysis and report.
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
club 4, risk factors for graft loss in 1st year post transplant
summary:
· The current study aimed to evaluate the risk factors for graft loss and found that:
o The age of both the donor and recipient, standard versus extended criteria donor, living versus deceased donor, degree of HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small.
o However, cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension have no effect on the graft survival at one year.
· Level of evidence: although they say that it is systemic review and meta-analysis, but (garbage in, garbage out). The included studies in the current analysis are all retrospective cohort, so at best level of evidence it is just level 2.
Hi Dr Shawky,
2a rather than 2 will be better way of stating the level of evidence.
Ajay
Dear team,
This is just a copy of what I replied to our colleague, Dr Ghalia,
I must say that you analysis I regards to the level of evidence this study provides is most wonderful. This triggers me to correct my response to level 2a rather than level 1a.
I like you contention as described in GIGO (garbage in, garbage out) for meta analyses. The level of meta analysis is as good as the articles used. If it has used poor quality studies it would become the level ‘a’ of the level of those studies.
Since this study includes cohort studies, it would qualify for a 2A level at the best. I do not know where there are studies that are case-control studies in this meta-analysis, the description is not so complete in this regard. To give the benefit of doubt, all the studies included would be cohort since they are talking about HR (there would be a time-line that subject are exposed to a hazard), not odds ratio (as in case-control).
Ajay
Materials and Methods
Data Sources and Searches
MEDLINE, EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations between the years 2000–2017.
Study Selection and Data Extraction
selected observational studies of adult (>18 years) kidney recipients receiving their first transplant, including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis.
Risk of Bias of Individual Studies
Quality in Prognostic Studies instrument
Data Synthesis and Statistical Analyses
Results
Study Selection and Characteristics
19,679 unique citations,
of which 2220 citations required full text review;
35 studies ultimately proved eligible
from Canada, Denmark, Germany, Ireland, Italy, Japan, Norway, Portugal, Spain, South Korea, Taiwan, United Kingdom, and United States.
Risk of Bias of Individual Studies
Meta-Analyses of Donor Factors
The review assessed six donor characteristics:
1. donor type (HR, 1.54 for deceased donors; 95% CI, 1.32 to 1.82; high certainty),
2. donor quality (HR, 1.35 for extended criteria donors; 95% CI, 1.28 to 1.42; moderate certainty due to risk of bias),
3. donor age (HR, 1.11 per 10-year increase; 95% CI, 1.04 to 1.18; high certainty),
4. donor sex (HR, 1.10 for female sex; 95% CI, 1.07 to 1.21; moderate certainty due to serious inconsistency),
5. donor (BMI) (HR, 0.90 per 10 kg/m2 increase; 95% CI, 0.82 to 0.91; moderate certainty due to serious risk of bias).
all studies defined
extended criteria donors:
• history of CVA
• hypertension,
• serum creatinine .1.5 mg/dl
delayed graft function
the need for dialysis within the first week post-transplant.
Meta-Analyses of Transplant Process Factors
Meta-Analyses of Recipient Factors
We identified nine transplant recipient variables
Four of the nine were significantly associated with 1-year death-censored graft loss:
1. recipient age (HR, 1.17 per 10-year increase; 95% CI, 1.09 to 1.25; high certainty),
2. pretransplant smoking (HR, 1.59; 95% CI, 1.34 to 1.90; moderate certainty due to serious imprecision),
3. pretransplant recipient coronary artery disease (HR, 1.15; 95% CI, 1.03 to 1.27; moderate certainty due to serious indirectness),
4. number of pretransplant years on dialysis (HR,1.03per1-year increase; 95% CI, 1.02 to 1.03; moderate certainty due to serious risk of bias).
Meta-Analyses of Post-Transplant Complications
DGF – AR
early post-transplant complications associated with death-censored graft loss
For both, we observed a statistically significant association with1year graft loss:
• DGF (HR, 1.89; 95% CI, 1.46 to 2.47; moderate certainty due to serious inconsistency) and
• AR (HR, 3.16; 95% CI, 1.86 to 5.38; moderate certainty due to serious inconsistency).
Strengths and Limitations
Some may be surprised that cold ischemia time was not associated with1-year graft loss.
Plausible explanation is that techniques such as machine perfusion and preservation solutions minimize cold ischemia damage to the kidney
Level 2a systematic review of cohort studies
Dear Dr Ghalia,
I must say that you analysis I regards to the level of evidence this study provides is most wonderful.
I like you contention as described in GIGO (garbage in, garbage out) for meta analyses. The level of meta analysis is as good as the articles used. If it has used poor quality studies it would become the level ‘a’ of the level of those studies.
Since this study includes cohort studies, it would qualify for a 2A level at the best. I do not know where there are studies that are case-control studies in this meta-analysis, the description is not so complete in this regard. To give the benefit of doubt, all the studies included would be cohort since they are talking about HR (there would be a time-line that subject are exposed to a hazard), not odds ratio (as in case-control).
Ajay
Thank you professor for your important notes
Summary of the article;
Although The kidney transplantation considered the best treatments of renal failure, successful of kidney transplantation is of great concern, studies, researches, which results in improving short and long term outcome and overall improving quality of life and recipients satisfaction.
With expanding the donor pool according to increasing demand by using ECD and poor quality kidneys to improve quality of life and to reduce waitlisting patients on dialysis.
So with improving managing grafted kidney 1 year graft survival is of great developing with good outcome.
Applied guidelines can aid clinicians to follow a proper approach regarding surgical and medical area of care.
Materials and Methods;
Data sources;
Collected from bibliographic databases in February 2017;
Study selection and data Extraction;
Risk of bias of individual studies;
Risk of bias had been assessed using the Qulaity in Prognostic studies instrument.
Results;
Discussion;
Strength of the study;
Limitations;
Level of evidence ((I)), Meta–analysis
I like your analysis and report.
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
*Kidney transplant recipients have the highest rate of graft survival among all organs transplanted : 92% 1-year graft survival for kidneys transplanted from deceased donors.
* 1-year graft survival may change. It is therefore useful to identify low-risk and high-risk kidney transplant cases.
Materials and Methods
* MEDLINE,EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations between the years 2000–2017.
* selected observational studies of adult (>18 years) kidney recipients receiving their first transplant, including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis.
* assessed the risk of bias of individual studies using the
Quality in Prognostic Studies instrument
* conducted meta-analysis for any risk factor evaluated in two or more studies.
Results
*Study Selection and Characteristics, The individual studies included patients from diferent countries.
*Risk of Bias of Individual Studies
Of the 35 eligible studies, reviewers judged 18 to have
high risk of bias
*Meta-Analyses of Donor Factor
The review assessed six donor characteristics; five were
independently associated with 1-year graft loss in the
original studies and also proved predictive in the metaanalysis (donor type, quality,age, sex, BMI)
*Meta-Analyses of Transplant Process Factors
risk factor variables characteristic of thetransplant process
-HLAmismatches
-cold ischemia time
-recipient sex,BMI,DM, dialysis, comorbidities, delayed graft , early acute rejection.
*Meta-Analyses of Recipient Factors
nine transplant recipient, Four of the nine were significantly associated with 1-year death-censored graft loss: recipient age, pretransplant smokingpretransplant recipient coronary number of pretransplant years on dialysis artery disease,
We did not observe a statistically significant association for recipient sex, race, BMI, hypertension, or diabetes with 1-year graft loss . We did not detect publication bias
for any of the recipient factors.
*Meta-Analyses of Post-Transplant Complications
For both, we observed a statistically significant association with 1- year graft loss:
delayed graft function and acute rejection
We did not detect publication bias for any of the post-transplant complication factors.
*Risk Factors Addressed in a Single Study
This review identified an additional 72 candidate risk factors, each evaluated in only one study.
Conclusion:
Risk facters associated with moderate to high 1- year graft loss are associated with recepient sex,Years on dialysis for recipient , donor extended criteria, high bmi, deseased donor.
Risk facters asscociated with high 1- yr graft loss are:
Donor age, deseased donors, cold ischemia time, HLA mismatch, increase recipient age, race, bmi, diabetes.
Hi Dr Esra,
I like that your headings in bold.
Your sub-headings too should be in bold or underline. That will make it easy to read.
Ajay
This review aims to evaluate the factors that supposed to influence the risk of one year graft loss in kidney transplant recipients .
– Design, setting, participants, & measurements:
databases from 2000 to 2017 , included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
– Results:
· 35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
· Six factors were associated with graft loss, with moderate to high degree of certainty: donor age 1.11 per 10-year increase, extended criteria donors, deceased donors , number of HLA mismatches , recipient age , and delayed graft function as risk factors for 1-year graft loss.
· Pooled analyses also excluded, with a high degree of certainty, any associations of cold ischemia time, recipient race, pretransplant body mass index, diabetes, and hypertension with 1-year graft loss.
– Conclusion :
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small
– Level of evidence :
Level 5 , narrative review
Thankyou clear and well read.
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Introduction
Prolongation of graft survival post transplantation is a crucial issue to avoid redialysis , retransplantation or death.
Renal graft survival is the highest among all organs transplanted,
Meanwhile 1 year graft survival is variable according to high or low risk kidney transplant cases.
Risk prediction models have limited performance as they cannot be generalised.
A meta-analysis can guide the development of a prediction model with useful discrimination and calibration .
Methods
Data was obtained from MEDLINE, EMBASE, Cochrane central register for controlled trials, and Cochrane database for systematic reviews for citations within 17 years including studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysis.
GRADE approach rating the certainty of evidence was used.
Results
Out of 35 eligible studies 18 had high bias risk.
Recipient diabetes and delayed graft function showed statistically significant different effect estimates in studies at high versus low risk of bias.
Donor type either deceased or living , donor quality either extended or standard , donor age, donor sex and BMI are independently associated with 1-year graft loss with different degree of certainty.
There was no significant association between donor serum creatinine level and the risk of 1-year graft loss.
HLA mismatches numbers was the only risk factor associated with 1-year death-censored graft loss.
Cold ischemia time wasnot associated with graft loss.
Recipient age, pretransplant recipient smoking, pretransplant coronary artery disease and number of pretansplant years on dialysis were significantly associated with 1-year death-censored graft loss.
Recipient sex, race, BMI, hypertension, or diabetes were not associated with 1-year graft loss.
Delayed graft function and acute rejection were considered as early post-transplant complications associated with death-censored graft loss.
Discussion
Strengths were that it is the first large-scale, systematic review of
studies that adjusted analyses for risk factors for 1-year graft loss post kidney transplantation.
These estimates can be useful by multiplying the HR of multiple risk factors to obtain their combined effect on the risk of 1-year graft loss.
GRADE method that was used facilitated detection of direction ,magnitude of association of each risk factors as well as certainty degree.
UNOS registry was included representing a highly referred to source by the transplant community.
The limitation is that included studies identified risk factors using Cox regression analysis for graft loss at all time points in follow-up thereby supposing that the studies authors ensured the proportional hazards assumption necessary for validity of any reported HR.
Also potential candidates for transplant can ne declined because of patient factors that were not included which could be the most important determinant of the outcome.
Cold ischemia was not associated with 1 year graft loss could be due to till a certain duration, there may be no relation between ischemia time and outcome, but beyond that duration graft longevity diminishes.
Other studies declared ischemia time can be associated with 1 year graft loss after a long period of time .
Out of the 34 identified models, 7 only predicted graft loss at 1-year
post-transplantation.
This review excluded an association beyond chance for each of these risk factors and 1-year graft loss.
Opposite to other studies this review excluded an association beyond chance for factors including recipient sex,age , BMI,DM,HTN,donor creatinine and cold ischemia time.
Inspite that other studies mentioned female gender association with better graft outcome due to hormonal effect , while this study did not reveal association due to the study short period .
Also lack of association with race due to lack of race disparities in kidney transplantation studies.
The inclusion of patient mortality may explain the lack of association between donor creatinine and mortality and cases with high creatinine were excluded.
Donor eGFR more than 60 ml/min /kg were associated
with a decrease in risk of graft loss at 1-year postkidney transplantation.
Guidelines implications
Risk prediction models to direct selection of candidates whose risk for graft loss can be higher than their risk of mortality on dialysis.
Conclusion
10 risk factors associated with 1-year graft survival having moderate or high strength certainty include recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches.
Risk factors without large associations with 1-year graft survival having high certainty includes increasing cold ischemia time, recipient BMI, recipient diabetes, and recipient hypertension .
-Level of evidence is 5 because the evidence was obtained from systematic reviews of descriptive and qualitative studies
Excellent just add to the moderate,high strength DGF.
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Introduction:
Ø Kidney transplant recipients have the highest graft survival rate among all transplanted organs: 92% 1-year graft survival for kidneys transplanted from deceased donors.
Ø Prognostic studies can guide clinicians and patients in better understanding factors associated with a higher risk of graft loss in the first year post-transplantation.
Materials and Methods:
Ø Cochrane central register for controlled trials and Cochrane database for systematic reviews for citations between 2000 and 2017.
Ø Observational studies of adult (18 years) kidney recipients are receiving their first transplant, including studies evaluating the association between risk factors and 1-year graft loss using multivariable analysis.
Ø The Author Applied the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment only to these studies. We used a two-sided P value of <0.05 to denote statistical significance. STATA’s mean function provided the platform for conducting all statistical analyses
Results:
1- 35 eligible studies, reviewers judged 18 to have a high risk of bias
2-The review assessed six donor characteristics; five were independently associated with 1-year graft loss in the original studies and also proved predictive in the meta-analysis
3-All studies defined extended criteria donors as >.60 years of age or age 50–59 years with two of three associated risk factors: history of cerebrovascular accident, hypertension, or serum creatinine .1.5 mg/dl and delayed graft function as the need for dialysis within the first week post-transplant
4-There is no statistically significant association between donor serum creatinine level and the risk of 1-year graft loss
5-The number of HLA mismatches was the only risk factor, for which we observed an association beyond chance, with 1-year death-censored graft loss
6-Not observe a statistically significant association for recipient sex, race, BMI, hypertension, or diabetes with 1-year graft loss
7-Identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease
Strength:
1-large-scale, a systematic review of studies
2-Using rigorous meta-analytic methods
3-The use of GRADE methodology
Limitation :
1- studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up
2-UNOS registry data.
level 5
Thankyou well done
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
SUMMARY
Introduction
The kidney transplantation is the beginning of another journey although with better quality of life as the attention is shifted toward ensuring graft longevity. The scarcity of organ for transplantation has resulted in extended donor criteria to make more organ available but this has also come up with question on the 1- year graft survival compared to organ from standard criteria
Aim of the study
Materials and Methods
Results
Strength of the study
Limitation of the study
Conclusion
It is of note that this study has been able to report both donor and recipient factors that could affect the one-year graft survival following kidney transplant, and this will help the attending physicians in patient selection for the kidney transplant
The level of evidence is 5
Thankyou for your conclusion for choosing the recipient.
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Kidney transplant is associated with high (92%) 1-year graft survival. It is important to identify high-risk and low-risk kidney transplant cases. The article evaluated 35 studies from multiple countries to assess influence of certain risk factors over 1-year graft loss in kidney transplant recipients. It also included unpublished data from clinical experts. The risk of bias of individual studies was assessed using Quality in Prognostic Studies instrument and GRADE approach was used to assess the certainty of evidence.
Association between graft loss and donor characteristics: Donor age and donor type (deceased) had high certainty association with graft loss while donor quality (extended criteria), donor gender (female) and donor BMI (lower) had moderate certainty association with graft loss. Donor serum creatinine did not have any association with graft loss.
Association between graft loss and transplant process factors: Number of HLA mismatch was associated with high certainty with no effect of cold ischemia time.
Association between graft loss and recipient factors: Recipient age was associated with high certainty, while pre-transplant number of years on dialysis, smoking and coronary artery disease were associated with moderate certainty. Recipient gender, race, BMI, hypertension, and diabetes were not associated with graft loss.
Association between graft loss and post-transplant complications: Acute rejection and delayed graft function were associated with moderate certainty.
Strength of the study: First large scale review, use of GRADE methodology to report on the certainty of the evidence, individual hazard ratios of the risk factors can be multiplied to get combined effect of multiple risk factors.
Limitations of the study: Included unpublished data and included registry data (hence the quality of the review is as good as the quality of the registry data). The included studies varied considerably in the covariates included. Another limitation is because of the nature of the studies, recipients with multiple co-morbidities might not have been included in the transplant program, hence the assessment of effect of multiple risk factors which were not included could not be studied. Another limitation is the nature of the study, looking at only 1-year graft loss data.
Conclusion: 1 year graft loss post kidney transplant depends on donor age, donor type, donor quality, HLA mismatch, recipient age, delayed graft function as well as donor BMI and gender, and recipient coronary artery disease, smoking and dialysis vintage.
2. What is the level of evidence provided by this article?
Level of evidence: level 5 – Narrative review
Although written as systematic review, this does not include any randomized controlled trial. It has also included unpublished studies.
Thankyou very well organized and comprehensive.
Summary
This study is about the factors that might lead to loss of graft within one year post transplant.
Some of the factors that can affect one year graft loss rate are
Cold ischemia time however, has been identified to not be associated with increased risk of graft loss. Machine perfusion might be the answer to this that mitigates risk.
In addition, donor creatinine was found to have no association with 1 year graft loss. However, this could be a false association due to the fact that donors with worse creatinine levels were not selected for transplantation.
Each factor on its own has a small effect, however, with more than one factor combined the effect on graft survival and patient survival can be significant. Graft loss means that the patient has to undergo transplant again, or go back to dialysis or in some cases, graft loss can lead to death.
Level of evidence
This article is a systematic review and meta analysis, hence level of evidence is 1.
Thankyou narrative review level 5
This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
The aim of the study;
—————————-
was to evaluate factors purported to influence the risk of 1-year graft loss in kidney transplant recipients.
The study type ;
———————————–
Systemic review .
The design ;
———————–
The study searched bibliographic databases from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss.
The literature search identified 19,679 unique citations, of which 2220 citations required full text review; 35 studies ultimately proved eligible.
Inclusion criteria ;
——————————-
1-observational studies of adult ($18 years) kidney recipients receiving their first transplant.
2-studies evaluating the association between any risk factors and 1-year graft loss using multivariable analysi.
The result ;
———————–
1-This review identified five risk factors, for which there is moderate to high certainty in the magnitude of association with 1-year graft loss: donor age, extended criteria donors,
deceased donors, increasing number of HLA mismatches, and recipient age.
2-The study identified an additional five variables for which, with moderate certainty, there is an association with 1-year graft loss: donor sex, donor BMI, recipient’s number of years on dialysis, history of smoking, and coronary artery disease.
3-With high certainty, the findings of this study exclude any association of the following variables with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, and recipient hypertension.
Strengths;
——————————-
1-It is a large-scale, systematic review .
2-Using rigorous meta-analytic methods, the review provides precise measures ,compared with any individual study, for the association of each risk factor and graft loss, informed by observational cohort studies.
3-The use of GRADE methodology enabled us to not only report on the direction and magnitude of the association for each risk factor, but also to transparently report on the certainty of the evidence.
Limitations;
————————–
1-The study included United Network for Organ Sharing (UNOS) registry studies to represent all studies published from individual centers in the United States. By doing so, the quality of this review is dependent upon the quality of the UNOS registry data.
2-potential candidates for transplant may be rejected because of patient factors that were not included. These may include, but not be limited to active infections and combination of older age with constellation of other comorbidities such as obesity, cardiovascular disease, malignancies, and irreversible obstructive or restrictive pulmonary disease .
Conclusion ;
—————————–
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small.
What is the level of evidence provided by this article?
———————————————————————-
Level I
HI Dr Ishag,
Your headings and sub-headings should be in bold or underline. That will make it easy to read.This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
Ajay
Please summarise this article
Introduction
With expansion of the pool of kidney grafts with the use of use of higher risk donors, graft survival may be changed. So, identification of these risk factors is important
Aim of the study
Assess risk factors for kidney graft survival at 1 year post-transplant
Materials and Methods
The study searched bibliographic databases (2000 -2017) and included observational studies of adult kidney recipients receiving their first transplant, including studies evaluating the asso ciation between any risk factors and 1-year graft loss using multivariable analysis
Results
19,679 citations were identified, of which 35 studies proved eligible
Excluding patients with early graft survival (any study that excluded patients with graft survival less than 1 year)
Six donor characteristics; five were independently associated with 1-year graft loss (donor type, donor quality, donor, donor sex, and donor BMI)
Insignificant association between donor serum creatinine level and the risk of 1-year graft loss
Nine transplant recipient variables were identified, four of the them were significantly associated with 1-year death-censored graft loss (recipient age, pretransplant smoking, pretransplant recipient coronary artery disease, and number of pretransplant years on dialysis)
Discussion
The study identified five risk factors donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, and recipient age
Limitations of the study
1. studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up were included
2. Results are vulnerable to the possibility that the effect of a particular risk factor might differ depending on which variables were included in a particular model
3. potential candidates for transplant may be rejected because of patient factors that were not included
Conclusions
1-year graft survival is predicted by recipient age, donor age, extended criteria donors, deceased donors, and increasing number of HLA mismatches
What is the level of evidence provided by this article?
Level 1 (systemic review and meta-analysis)
HI Dr Abdallah,
I could not understand why Cox Regression analysis would be a limitation?
Ajay
Summary:
Aim of the study:
To assess the risk factors for graft survival at 1-year post-transplant.
Methods:
Results:
35 eligible primary studies, with 20 risk factors amenable to meta-analysis.
Six factors were associated with graft loss, with a moderate to a high degree of certainty: donor age, extended criteria donors, deceased donors, number of HLA mismatches, recipient age, and delayed graft function as risk factors for 1-year graft loss.
Pooled analyses also excluded any associations of cold ischemia time, recipient race, pretransplant body mass index, diabetes, and hypertension with 1-year graft loss.
Conclusion:
Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small.
Strengths:
Limitations:
This meta-analysis included studies identifying risk factors using Cox regression analysis for graft loss at all time points in follow-up.
Level of Evidence:
Level 1 (systematic review and meta-analysis).
Dear Dr Huda,
I could not understand why Cox Regression analysis would be a limitation?This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay
1. Please summarise this article
Introduction
With the increasing use of high risk donor in an attempt to expand donors pool, it is important to understand factors associated with a higher risk of graft loss in the 1styear post-TX.
The objective of this study is to assess the predictive power of key risk factors for kidney graft survival at 1 year post-TX.
Study design
Search of bibliographic databases from 2000 to 2017, including observational studies that assessed the link between donor, recipient, TX operation, or early postoperative complications, & 1-year death-censored graft loss.
Results
35 eligible primary studies were identified, with 20 risk factors subjected to meta-analysis.
6 factors were associated with graft loss (1-year graft loss), with moderate to high degree of certainty:
1. Donor age
2. ECDs
3. Deceased donors
4. Number of HLA mm
5. Recipient age
6. DGF
The analyses excluded (with a high degree of certainty) any associations of the following with 1-year graft loss:
1. CIT
2. Recipient race
3. Pre-transplant BMI
4. Diabetes
5. Hypertension
Discussion
Main findings
Risk factors significantly associated with 1-year graft loss are: donor age, extended criteria donors, deceased donors, increasing number of HLA mismatches, & recipient age. Additional 5 variables were also identified: donor sex, donor BMI, recipient’s number of years on dialysis, H/O smoking , & CAD.
This study exclude any association of the following with 1-year graft loss: increasing cold ischemia time, recipient age, recipient BMI, recipient diabetes, & recipient hypertension.
Strengths and Limitations
The study is the 1stlarge-scale, systematic review of risk factors for 1-year graft loss after KTX.
Precise measures were reviewed using rigorous
meta-analytic methods.
The use of GRADE methodology allowed report on the direction & magnitude of the association for each risk factor.
Limitation:
Assumption that the authors of the primary studies had tested & ensured the proportional hazards assumption necessary for validity of any reported HR; however, the authors of the individual studies
seldom reported on assessing the necessary assumptions of their regression models. So, the statistical analysis for the risk of bias assessment could not be fully informed by meeting the regression model assumptions.
/////////////////////////////////
2. What is the level of evidence provided by this article?
Level I
Dear Dr Mohamed,
I could not understand why assumptions in performing regression analysis would be a limitation? This study provides levels 2A evidence, please read my response to Dr Ghalia.
Ajay