Long-term outcomes in renal transplantation

Th e aim of off ering renal transplantation to patients with end-stage renal failure is to achieve a longer and better quality of life than can be achieved with dialysis therapy. For most patients this is being achieved, but the longterm results come nowhere near what could be expected for the normal age-matched population. Th e Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) shows that for patients transplanted with a primary deceased donor graft from 1995 to 2000 in Australia and New Zealand, 72% were alive 10 years after transplantation [1]. Of these, 20% had returned to dialysis therapy. Only 59% of these patients were thus alive with a functioning graft after 10 years. Th e death rate after the fi rst year for this cohort of patients is 2.5% per year. Deaths in the fi rst few years relate to infection, with an increasing proportion due to malignancy and cardiovascular disease in later years. In 2010 in Australia, 32% of deaths in transplant patients were due to malignancy, compared with 23% from cardiac or vascular disease and 22% from infection [1]. Whereas improvements in immunosuppression and surgical and medical advances have resulted in shortterm gains, the long-term outcomes have not improved. To illustrate this fact we have analysed ANZDATA for graft failure rates for transplants performed between 1970 and 2009. Over those decades the graft failure rates have fallen substantially for the fi rst year and to a lesser degree for the time periods of 1 to 4.9 years and 5 to 9.9 years. For those grafts surviving 10 years, however, the subsequent annual failure rate has increased over time (Figure 1).