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Long-Term Renal Allograft Survival in the United States: A Critical Reappraisal

2010; Elsevier BV; Volume: 11; Issue: 3 Linguagem: Inglês

10.1111/j.1600-6143.2010.03283.x

1600-6143

Kenneth Lamb, Sundus A. Lodhi, H.-U. Meier-Kriesche,

Renal and Vascular Pathologies

American Journal of TransplantationVolume 11, Issue 3 p. 450-462 Free Access Long-Term Renal Allograft Survival in the United States: A Critical Reappraisal K. E. Lamb, K. E. Lamb Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, FLSearch for more papers by this authorS. Lodhi, S. Lodhi Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, FLSearch for more papers by this authorH.-U. Meier-Kriesche, Corresponding Author H.-U. Meier-Kriesche Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, FL Corresponding author: Herwig-Ulf Meier-Kriesche, meierhu@medicine.ufl.eduSearch for more papers by this author K. E. Lamb, K. E. Lamb Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, FLSearch for more papers by this authorS. Lodhi, S. Lodhi Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, FLSearch for more papers by this authorH.-U. Meier-Kriesche, Corresponding Author H.-U. Meier-Kriesche Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, FL Corresponding author: Herwig-Ulf Meier-Kriesche, meierhu@medicine.ufl.eduSearch for more papers by this author First published: 25 October 2010 https://doi.org/10.1111/j.1600-6143.2010.03283.xCitations: 646AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract Renal allograft survival has increased tremendously over past decades; this has been mostly attributed to improvements in first-year survival. This report describes the evolution of renal allograft survival in the United States where a total of 252 910 patients received a single-organ kidney transplant between 1989 and 2009. Half-lives were obtained from the Kaplan–Meier and Cox models. Graft half-life for deceased-donor transplants was 6.6 years in 1989, increased to 8 years in 1995, then after the year 2000 further increased to 8.8 years by 2005. More significant improvements were made in higher risk transplants like ECD recipients where the half-lives increased from 3 years in 1989 to 6.4 years in 2005. In low-risk populations like living-donor-recipients half-life did not change with 11.4 years in 1989 and 11.9 years in 2005. First-year attrition rates show dramatic improvements across all subgroups; however, attrition rates beyond the first year show only small improvements and are somewhat more evident in black recipients. The significant progress that has occurred over the last two decades in renal transplantation is mostly driven by improvements in short-term graft survival but long-term attrition is slowly improving and could lead to bigger advances in the future. Abbreviations: SRTR Scientific Renal Transplant Registry SCD Standard criteria deceased donor ECD Expanded criteria deceased donor Tx Transplant Rec/Don LE 45 Recipient and donor age less than or equal to 45 KM Kaplan-Meier Introduction The specialty of kidney transplantation has made dramatic strides over the decades evolving from an experimental procedure to the standard of care in the treatment of patients with end-stage renal disease (1). Not only are the outcomes after kidney transplantation good enough to improve the quality of life (2) of our patients, but it has also been established as a life-saving procedure (3, 4); yet the life-saving benefit of a kidney transplant lasts only as long as the transplanted kidney (4). Technical and pharmaceutical progress have helped to improve outcomes progressively even over the last decade when excellent outcomes were already considered standard of care. Now with graft survival rates in excess of 90% the question arises if any further improvements are possible or even necessary. In 2004 it became clear that the overall improvements in graft survival after kidney transplantation were really driven by improvements in first-year survival, whereas long-term graft attrition remained largely unchanged over decades (5, 6). This highlighted a whole other area where improvements might be possible and necessary. Especially now when first-year survival rates are almost close to perfect it becomes clear that further improvements in long-term survival have to come through improvements in long graft maintenance. It is notoriously difficult to measure long-term survival, as lengthy follow-up is necessary to document it, yet periodic updates on the long-term trends can potentially yield important information especially when counseling patients in the pretransplant phase regarding expectations of future outcomes. The purpose of our present study was to reevaluate the evolution of short- and long-term renal allograft survival in the United States with the most recent data provided by the Scientific Renal Transplant Registry (SRTR). Materials and Methods Subjects We examined data from the national SRTR database for renal transplant recipients from 1989 to November 1, 2009. Analyses were conducted on adult transplant recipients 18 years or older. Multiorgan transplants were excluded from the analysis. Data were analyzed separately for living and deceased-donor transplants, black recipients, nonblack recipients, first transplants and repeat transplants, for standard criteria donor (SCD) kidneys and expanded criteria donor (ECD) kidneys and for recipients with donor and recipient ages below 45 years. Outcome measures We analyzed graft, patient and death-censored graft survival by estimating survival half-lives and we analyzed attrition rates all stratified by year of transplant. Half-lives; Univariate half-lives were calculated as median half-lives, i.e. the intersection point of the Kaplan–Meier curve with the 50% survival threshold. We differentiated between actual half-lives for those instances where all patients had reached the 50% mark, actuarial half-lives for those instances when only a proportion of patients had reached the 50% mark and projected half-lives when none of the patients reached the 50% mark. In the tables and figures actual and actuarial half-life were grouped together but projected half-lives are shown separately. Projections were obtained by forecasting the Kaplan–Meier curves from a point of stable attrition, which was fairly consistently located between 3 and 8 years of survival yielding a period of 5 years from which the forecasts were based. Forecasted projections were carried out using ordinary least squares point estimates. Multivariate half-lives were obtained in the same fashion from the Cox proportional hazard models. Attrition rates; Attrition rates were calculated by first acquiring actual 1-year, 3-year, 5-year and 10-year survival rates. The total number of patients failed during the time period was subtracted from the number of patients originally entering the cohort and divided then by the original number entering the cohort to obtain an absolute failure percentage. The percentage of absolute failures was then divided by the total number of years in the follow-up interval to obtain a yearly failure rate. Independent variables Covariates used to calculate the adjusted half-lives from the Cox model included recipient's transplant age (reference group 18–34), pretransplant diagnosis of diabetes (reference group diabetic), candidate race (reference group Caucasian) and candidate gender (reference group males) summarized for transplant year 1999 to yield the most up-to-date case mix for complete 10-years follow-up (7). Statistical models Outcomes were measured by the Kaplan–Meier models and the Cox multivariate proportional hazard models. Half-lives were calculated based on actual and projected follow-up where applicable. Half-lives based on actual versus projected follow-up are displayed distinctly in the results. Projected half-lives were utilized in both the univariate Kaplan–Meier and the multivariate Cox Regression model for allograft failure and only in the univariate Kaplan–Meier for death-censored allograft failure. Multivariate models were corrected for the same variables uses in the SRTR annual data report as described above. Proportional hazard assumptions were tested by visually assessing log–log survival curves. The Exact method was used to handle tied outcome occurrences. All analyses were conducted using SAS (v.9.2, Cary, NC) and a type-one error probability of 0.05 was utilized as an indication of statistical significance. Results Patients We analyzed a total of 252 910 adult kidney recipients transplanted between 1989 and 2005 excluding multiorgan transplants. Of these, 164 480 were deceased-donor transplants and 88 430 living-donor transplants. Of 164 480 deceased-donor transplants 23 580 were ECD transplants. Of 140 900 deceased standard criteria donor recipients, 120 675 were first transplant recipients and 20 225 were repeat transplants. Graft survival Figure 1(A) shows overall graft survival for standard criteria deceased-donor transplants between 1989 and 2005 and the respective median half-lives based on where the survival curve crosses the 50% survival line. Figure 1Open in figure viewerPowerPoint (A) Kaplan–Meier cumulative graft failure and (B) death-censored graft failure, by year of first deceased SCD transplants from transplant year 1989–2008. Figure 1(B) shows death-censored graft survival for standard criteria deceased-donor transplants and the respective half-lives. Half-lives Table 1 displays the overall both actual or actuarial half-lives and the projected half-lives marked as ‘forecasted’ in the second shaded line by transplant year. The overlap between the actuarial half-lives and projected half-lives represents instances where still reasonable conclusions can be drawn from the actuarial data but forecast were generated in parallel. This gives a sense also about how well the forecasts might be working. Table 1. Kaplan–Meier estimates of cumulative graft half-lives by transplant year Transplant years All races 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 ECD/SCD (N = 164480) 6.6 6.7 7.2 7.1 7.3 7.3 7.8 7.9 8.2 8.4 8.6 8.2 ECD/SCD – forecasted 8.3 8.3 8.2 8.4 8.6 8.8 8.8 8.8 1st Tx – ECD/SCD (N = 142198) 6.8 6.9 7.3 7.1 7.4 7.4 8 8 8.3 8.5 8.6 8.4 1st Tx – ECD/SCD – forecasted 7.3 7.8 8 8.2 8.3 8.3 8.3 8.5 8.7 8.9 8.9 9 SCD (N = 140900) 6.7 6.9 7.4 7.3 7.7 7.8 8.4 8.6 8.9 9.0 9.2 8.8 SCD – forecasted 8.8 9.0 8.7 9.0 9.4 9.5 9.7 9.5 1st Tx – SCD (N = 120675) 7.0 7.1 7.5 7.4 7.8 7.9 8.5 8.8 9.0 9.2 9.3 9.0 1st Tx – SCD – forecasted 8.9 9.0 8.8 9.1 9.5 9.6 9.9 9.9 1st Tx – Rec/Don LE 45 (N = 40529) 7.7 7.6 8.5 8.4 9.2 9.0 9.7 10.6 10.2 10.5 1st Tx – Rec/Don LE 45 – forecasted 9.9 10.3 10.4 10.9 10.1 10.6 10.5 11.0 1st Tx – ECD (N = 21523) 3 3.7 4.4 4.2 3.7 4.8 5 5.5 5.1 5.4 5.4 5.6 5.5 5.8 1st Tx – ECD – forecasted 5.6 5.4 5.5 5.6 5.6 5.7 5.8 6.4 5.9 6.4 Living donor (N = 88430) 11.4 11.6 11.6 11.4 11.5 11.1 11.2 11.8 12.0 Living donor forecasted 11.1 10.8 11.8 11.4 11.9 12.9 12.3 12.5 12.7 13.6 14.2 11.9 Living donor 1st Tx (N = 76579) 11.4 11.6 11.8 11.4 11.5 11.2 11.4 12.0 12.0 Living donor 1st Tx – forecasted 11.3 11.0 12.0 11.5 12.3 12.7 12.4 12.6 12.9 13.9 14.1 12.0 Nonblack/black 1 ECD/SCD (N = 117584/46896) 7.6/4 7.5/4.6 7.9/5 7.9/5 7.9/5.3 8.1/5.5 8.8/5.7 8.8/6.2 9.1/6.3 9.4/6.5 /6.4 /6.3 /6.9 ECD/SCD – forecasted 9.1/ 9.2/ 9/6.4 9.3/6.9 9.5/7 9.6/7.3 9.6/7.2 9.8/7.1 SCD (101072/39828) 7.8/4.1 7.8/4.8 8.2/5.1 8.2/5.2 8.4/5.6 8.6/5.8 9.3/6 9.5/6.7 10/6.8 9.9/7 10/7 /6.7 /7.2 SCD – forecasted 9.8/7 10/6.9 9.5/6.8 10/7.3 10.4/7.4 10.4/7.7 10.7/7.7 10.9/7.4 1st – Tx ECD (14956/6567) 3.7/1.8 4.1/3.2 4.8/2.9 4.6/3.4 5.5/2.3 5/3.1 5.5/4.3 5.8/4.7 5.7/4.4 6/4.2 6.3/4.5 6.1/4.1 5.8/5 6.1/4.9 /5 1st – Tx ECD – forecasted 6.3/4.3 6/5.1 6.2/4.9 6.9/5.2 6/5.4 6.6/5.7 1st Tx – Rec/Don LE 45 (N = 27253/13276) 8.9/4.4 8.8/5.1 9.8/5.4 9.7/5.9 10.9/5.9 10.6/6.3 11.5/6 12/7.7 11.9/7.6 /7.2 /7.7 /7.9 /7.7 1st Tx – Rec/Don LE 45 – forecasted 11.9/7.3 12.2/7.3 12.5/7.7 14.5/7.5 12.3/7.5 13.2/7.7 11.2/7.9 16.5/8 Living donor (N = 75640/12790) 12.3/6.3 12.1/7 12.6/8.5 12.1/7.6 12.2/7.7 11.9/7 12/7.4 12.7/7.6 /8.7 /9.5 Living donor forecasted 12.9/ 12.3/ 12.2/9.9 13.4/9.2 13/9.2 13.6/8.5 13.4/9.4 14.8/9.1 14.9/10.8 13.5/7.5 1Nonblack-recipient half-lives listed before hash mark followed by black recipients after the hash mark. Where no half-life could be obtained respective years are blank. Shaded rows are projections. When evaluating all 164 480 deceased-donor transplants jointly, the half-life was 6.6 years in 1989, increased to close to 8 years in 1995, stayed around 8 years until transplant year 2000 and then further increased to 8.8 years in 2005. When looking only at first-donor transplants (N = 142 198) excluding retransplants, the half-life was 6.8 years in 1989, increased to 8 years in 1995 and increased to 9 years in 2005. When limiting the analysis to just standard criteria deceased-donor transplants but including retransplants (N = 140 900) the half-lives improved from 6.7 years in 1989 to 9.5 years in 2005. Slightly (but not dramatically) better half-lives were achieved in first standard criteria kidney graft recipients (N = 120 675). When donor and recipient age was limited to less than 45 (N = 40 529), graft half-lives improved from 7.7 years in 1989 to 11 years in 2005. First ECD transplant (N = 21 523) half-lives were dramatically lower with 3 years half-life for first deceased-donor ECD transplants in 1989 that increased to 6.4 years in 2005. Living-donor transplant (N = 88 430) half-lives were substantially higher than deceased-donor half-lives but there was no appreciable change in living-donor half-life over the years. Whether repeat transplants were included or not half-lives were 11.4 years in 1989 and 11.9–12 years in 2005. When dividing the populations into black versus nonblack recipients the half-lives display the well-known outcomes difference between blacks and nonblacks. There has been a similar absolute increase in graft half-lives when comparing nonblack and black recipients, with a modest improvement in black ECD kidney half-life when comparing an increase in 3.9 years from 1989–2005 to only 2.9 years in nonblack ECD half-life over the same time period. Black standard criteria deceased-donor (N = 39 828) transplant half-life increased from 4.1 years in 1989 to 7.4 years in 2005; however, this was still substantially lower than nonblack (N = 101 072) half-life in the same year (10.9 years). Living-donor transplant half-lives in 1989 were 6.3 years in black recipients and 12.3 years in nonblack recipients. In 2005 living-donor recipient half-lives were 7.5 years in black versus 13.5 years in nonblack patients. Figure 2(A) contrasts the overall half-lives between first living-donor transplants and first standard criteria deceased-donor transplants. Figure 2(B) contrasts first standard criteria deceased-donor graft survival between black and nonblack recipients. Figure 2Open in figure viewerPowerPoint Actuarial (diamond marker, solid line) and projected (round marker, dotted line) cumulative half-lives. (A) First SCD deceased versus first living donor and (B) first SCD deceased black versus nonblack recipients. Table 2 displays the death-censored graft half-lives by transplant year. Death-censored half-lives for all deceased-donor kidneys were 10.2 years in 1989 and increased to 14.3 years in 2005. Death-censored graft half-lives for standard criteria deceased-donor transplants have increased from 10.6 years in 1989 to 15.5 years in 2005. When deceased-donor transplants were limited to first transplants and both donor and recipient age of less than 45, death-censored graft half-life was 10.1 years in 1989 and 12.4 years in 2005. Table 2. Kaplan–Meier estimates of death-censored graft failure half-lives by transplant year Transplant years Recipient population 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 ECD/SCD 10.2 10.6 11.1 11 11.1 11.9 12.8 12.6 ECD/SCD – forecasted 11.4 11.4 12.5 12.1 12.9 13.1 14 14.2 15.1 14.4 14.3 1st Tx – ECD/SCD 11 11.1 11.5 11.4 11.7 12.1 13.3 12.9 1st Tx – ECD/SCD – forecasted 11.6 11.8 11.7 12.7 12.6 13.1 13.7 14.4 14.4 15.8 14.9 14.6 SCD 10.6 11.0 11.6 11.6 11.8 13.0 14.0 SCD – forecasted 12.0 12.2 12.3 13.5 13.0 13.9 13.9 15.2 15.3 15.7 15.8 15.5 1st Tx – SCD 11.3 11.4 12.0 12.2 12.3 13.1 1st Tx – SCD – forecasted 12.3 12.7 12.7 13.8 13.5 14.1 14.6 15.8 15.7 16.5 16.5 16.1 1st Tx – Rec/Don LE 45 10.1 10.1 11.0 11.1 11.9 11.8 12.0 12.9 1st Tx – Rec/Don LE 45 – forecasted 11.2 10.6 11.5 11.5 11.4 12.5 12.9 13.5 12.3 13.1 12.5 12.4 1st Tx – ECD 4.3 5.9 6.5 5.9 5.4 7.4 7.8 7.6 8.5 8.7 9.2 1st Tx – ECD – forecasted 7.7 8.3 8.3 9.1 9.5 9.1 9.6 12.8 9.9 10.1 Living Donor 16.5 16.3 16.7 16.7 16.0 Living donor forecasted 15.6 15.8 14.9 15.5 16.4 16.3 17.8 19.4 19.4 19.6 21.3 20.9 23.6 16.6 Living donor 1st Tx 16.5 16.2 17.7 16.7 16.0 Living donor 1st Tx – forecasted 15.8 15.2 16.0 16.8 16.4 18.4 19.5 19.8 19.8 22.4 22.0 23.9 16.8 Nonblack/black 1 SCD 12.8/5.2 12.7/6.4 14/7.2 14.3/7 13.8/8 15/6.3 /8.2 /9.3 /9.3 /9.8 /9.7 /9 SCD – forecasted 14.4/ 15.1/ 14.2/ 16.4/ 15.6/8.9 16.8/9.2 17.1/9.3 19.9/9.9 19.4/10.1 19.6/10.5 18.8/11.1 21.2/10 1st – Tx ECD 5.2/2 6.6/3.7 7.3/3.7 6.5/4.5 6.5/2.9 8.7/5.1 9/5.6 8.3/6.6 9.8/5.9 9.8/6.2 /5.9 /6.4 /7.1 1st – Tx ECD – forecasted 10.7/7 11.3/6.9 14.2/10.1 10.4/8.4 11.9/7.5 1st Tx – Rec/Don LE 45 12.6/4.7 11.9/6 13.6/6.2 14.4/6.9 14.9/7 13.9/7.8 /7.1 /9.5 /8.7 /8 /9.2 /8.7 1st Tx – Rec/Don LE 45 – forecasted 14/ 13.9/ 13.5/ 13.7/ 14.1/7.9 16.5/8 16.6/9 21.2/8.3 15.6/8.7 17.9/8.9 13.8/9.9 19.7/8 ECD/SCD 12.5/5.1 12.4/6.3 13.3/6.9 13.3/6.8 12.9/7.6 14.4/7.8 /7.9 /8.6 /8.7 /9.2 /9.2 /8.9 ECD/SCD – forecasted 13.2/ 13.7/ 12.9/ 15/ 14.4/ 15.7/8.5 16/8.8 18/9.3 17.6/9.6 18.4/10.4 16.6/10.6 19.2/9.3 Living donor 17.4/9.3 17.2/9.2 17.7/10.2 /9.2 /9.4 /8.9 /9.7 /10.3 /12.0 Living donor forecasted 17.3/ 16.5/ 17.4/ 16.9/ 17.6/8.9 18.4/9.5 18.1/10.2 18.9/12.6 21.6/12 21.4/12.1 22.9/10.8 24/12.5 24.4/11.3 26.2/15.7 20.9/8.4 1 Nonblack-recipient half-lives listed before hash mark followed by black Recipients after the hash mark. No KM half-life reported for respective year where blank. Shaded rows are projections. First ECD transplant death-censored half-lives increased from 4.3 years in 1989 to 10.1 years in 2005. Living-donor death-censored half-life was 16.5 years in 1989 and 16.6 years in 2005. Standard criteria deceased-donor half-life was 5.2 years in black recipients in 1989 versus 12.8 years in nonblack and 10 years in 2005 in black versus 21.2 years in nonblack. In contrast to cumulative graft half-life, death-censored half-lives were notably more improved from 1989 to 2005 in nonblack recipients as compared to black recipients. Death-censored standard criteria kidney half-life was 12.8 years and forecast to be 21.2 years in 2005, resulting in an increase by 8.4 years for nonblack recipients. Death-censored black standard criteria half-life is forecast to only increase by 4.8 years by 2005. Similar trends are seen in death-censored ECD, recipient and donor age less than 45 and living-donor half-lives. Figure 3(A) contrasts standard criteria deceased-donor first transplants with first living-donor transplants and Figure 3(B) contrasts first standard criteria deceased-donor transplants between black versus nonblack patients. Figure 3Open in figure viewerPowerPoint Actuarial (diamond marker, solid line) and projected (round marker, dotted line) death-censored half-lives. (A) First SCD deceased versus first living donor and (B) first SCD deceased black versus nonblack recipients. Table 3 displays the adjusted half-lives derived from the Cox proportional hazard models. The adjusted half-lives show similar patterns to the unadjusted half-lives. The adjusted standard criteria deceased-donor half-life in 1989 was 6.6 years and 9.9 years in 2005. For living-donor transplants the adjusted half-lives were 11.4 years in 1989 and 12.2 years in 2005. Table 3. Cox adjusted estimates of cumulative graft failure half-lives by transplant year Transplant years All races 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 SCD 6.6 6.7 7.3 7.2 7.6 7.8 8.3 8.6 8.9 9.0 9.3 8.9 SCD – forecasted 8.9 9.1 8.7 9.1 9.5 9.7 10.0 9.9 1st Tx – SCD 6.9 6.9 7.4 7.2 7.7 7.9 8.5 8.8 9.0 9.3 9.3 9.0 1st Tx – SCD – forecasted 9.0 9.1 8.9 9.3 9.7 9.9 10.2 10.2 1st Tx – SCD – Rec/Don LE 45 7.6 7.5 8.4 8.4 9.2 9.1 9.7 10.7 10.3 10.5 1st Tx – SCD – Rec/Don LE 45 – forecasted 10.0 10.3 10.6 11.0 10.0 10.9 11.1 11.0 Living donor 11.4 11.6 11.6 11.3 11.5 11.1 11.4 11.8 12.0 Living donor forecasted 11.2 10.9 11.9 11.5 12.0 12.7 12.3 12.6 12.9 13.7 14.3 12.2 Living donor 1st Tx 11.3 11.6 11.9 11.3 11.5 11.3 11.4 12.0 11.4 Living donor 1st Tx – forecasted 11.4 11.2 12.1 11.6 12.3 12.8 12.5 12.6 13.1 14.1 14.3 12.2 Nonblack/black 1 SCD 7.8/4.1 7.8/4.7 8.3/5.1 8.2/5.2 8.4/5.6 8.7/5.9 9.4/6 9.6/6.7 10/6.8 10/7 10/7 /6.8 /7.2 SCD – forecasted 9.8/7 10.1/6.9 9.6/6.8 10.1/7.3 10.5/7.4 10.6/7.7 11/7.9 11.1/7.5 1st – Tx SCD 8.2/4.3 8/4.8 8.4/5.1 8.3/5.2 8.6/5.6 8.7/6 9.6/6.2 9.7/6.7 10.2/6.9 10/7.1 10/7 /6.9 /7.4 1st – Tx SCD – forecasted 10/7 10.1/6.9 9.9/6.9 10.2/7.4 10.7/7.4 10.8/7.8 11.2/8.2 11.6/7.5 1st Tx – SCD – Rec/Don LE 45 9.3/4.3 9.1/5.1 10.3/5.4 9.9/5.8 11.3/5.9 10.8/6.3 11.7/6 12.2/7.7 11.9/7.6 /7.2 /7.5 /7.9 /7.7 1st Tx – SCD – Rec/Don LE 45 – forecasted 12.1/7.2 12.3/7.3 12.5/7.7 14.3/7.4 12.2/7.1 13.2/7.7 11.4/9.1 14.4/7.2 1Nonblack-recipient half-lives listed before hash mark followed by black Recipients after the hash mark. No KM half-life reported for respective year where blank. Shaded rows are projections. Graft attrition rates Table 4 displays the graft attrition rates by transplant year, where both graft loss and patient death are counted as an event. As also shown in Figure 4, for all categories the 0–1 year attrition rate improved dramatically and progressively since 1989. The 1–3, 3–5 and 5–10 year attrition rates show also small but consistent improvements. Table 4. Kaplan–Meier estimates of cumulative graft attrition rate by transplant year for first-transplant deceased donor All recipients Transplant years 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 0–1 Year 19.8 18.2 15.6 15.1 15.7 14.5 12.3 11.1 10.0 9.2 10.7 10.3 9.2 9.3 9.0 8.3 8.4 8.2 7.4 6.7 1–3 Years 7.4 6.7 6.1 6.6 6.1 5.7 5.4 5.4 5.5 5.0 5.2 5.5 5.4 5.5 5.4 5.3 5.1 4.7 3–5 Years 6.7 7.4 7.7 7.8 6.9 7.5 7.3 6.9 6.9 6.7 6.7 6.5 6.5 6.3 5.8 6.0 5–10 Years 7.5 7.5 7.8 8.0 7.3 7.4 6.9 6.9 6.8 6.9 6.6 Recipient and donor age below 45 0–1 Year 18.4 17.2 13.9 13.4 13.5 12.4 10.5 8.9 8.3 7.4 8.8 7.9 6.4 7.1 7.6 6.4 6.8 5.7 5.8 5.4 1–3 Years 7.5 6.8 5.6 6.4 5.8 5.2 5.1 5.1 5.1 4.9 5.1 5.5 5.0 5.2 5.6 5.4 4.6 4.7 3–5 Years 6.3 6.9 6.4 6.9 5.5 6.6 6.6 6.5 6.4 6.3 5.5 5.6 5.3 6.4 5.2 5.7 5–10 Years 6.7 6.8 6.8 6.7 6.0 6.4 6.2 5.3 5.8 5.7 5.4 Nonblack/black1 0–1 Year 18.3/24.2 17.6/20.2 17.9/14.8 17.6/14.3 15.5/17.5 14/15.7 12/12.9 10.4/12.9 9.9/11.6 8.7/10.7 9.9/12.5 9.1/13 8.3/11.4 8.8/10.4 8/11.2 7.5/10.1 7.7/9.9 7.8/9 6.4/9.2 5.8/8.4 1–3 Years 11.8/6.2 5.5/10.7 4.9/9.9 5.5/9.9 5/9.4 4.5/8.8 4.2/8.5 4.4/8 4.5/7.9 4.3/7 4.1/8.1 4.4/8.2 4.6/7.1 4.8/7.3 4.5/7.3 4.3/7.7 4.2/7.1 4.1/6.2 3–5 Years 5.7/10.4 6.4/10.7 6.6/11.6 6.9/10.8 6.1/9.7 6.6/10.1 6.3/10 6/9.4 5.8/9.7 5.6/9.8 6/8.7 5.8/8.2 5.8/8.2 5.4/8.3 5.3/7.2 5.5/7.2 5–10 Years 6.8/10.7 7/9.4 7.4/9.4 7.4/10.2 6.8/9 6.7/9.5 6.3/8.7 6.4/8.4 6.2/8.6 6.4/8.1 6.2/7.7 Recipient and donor age below 45 0–1 Year 17.3/21.8 16.3/19.8 13.1/16.1 12.8/14.9 12.6/16 12/13.3 10.1/11.4 7.9/11.1 7.9/9 6.2/9.6 7.3/11.9 6.9/9.7 6/7.4 6.1/8.7 6.6/9.4 4.9/9.1 6.5/7.2 5.3/6.2 4.2/8.1 3.8/7.9 1–3 Years 6/12.5 5.1/11.2 3.9/10.5 5/9.9 4/10.7 3.8/8.4 3.7/8.3 3.9/7.7 3.9/7.7 3.5/7.8 3.8/7.9 4/8.2 3.9/7.1 4/7.3 4.2/8.1 4/8.1 3.2/6.6 3.6/6.5 3–5 Years 5.1/10.9 6.1/9.4 5.1/10.9 5.6/10.7 4.6/8.6 5.4/9.6 5.4/9.6 5.3/9.1 5.1/9.3 5.1/9 4.3/8.2 4.5/7.8 3.5/9.1 4.8/9.4 4.3/6.9 5.3/6.5 5–10 Years 6.1/9.1 6.2/9 6.3/8.4 6/8.7 5.4/8.2 5.7/8.5 5.2/8.7 5/6.4 5.1/7.5 4.8/7.8 5/6.3 1Nonblack recipient half-lives listed before hash mark followed by black recipients after the hash mark. Figure 4Open in figure viewerPowerPoint Cumulative graft failure yearly attrition rates of first kidney transplants (A) Deceased SCD donor, (B) living donor, (C) Nonblack deceased SCD donor and (D) black deceased SCD donor. Figure 4 shows graft attrition rates for (A) standard deceased-donor kidney recipients, (B) living-donor kidney recipients, (C) nonblack standard deceased-donor recipients and D) black standard deceased-donor recipients. Compared to nonblack SCD attrition rates, black SCD attrition rates showed a modest improvement in the attrition rates for years 1–3, 3–5 and 5–10. Table 5 displays the death-censored graft attrition rates counting only graft failure as an event and censoring in case of death. For donor and recipient age below 45, the death-censored graft attrition rates have changed very little. Three to five years graft attrition was 5.0% per year in 1989 and 4.7% in 2004. Comparing black to nonblack patients there is a substantially higher long-term attrition rate in black recipients. In 1989 the 3–5 year attrition rate in blacks was 8.7% versus 3.2% in nonblacks and 4.9% in blacks in 2004 versus 3% in nonblacks. Table 5. Kaplan–Meier estimates of death-censored graft attrition rate by transplant year for first-transplant deceased donor Transplant years 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 All recipients 0–1 Year 15.7 14.3 12.3 11.3 12.0 10.8 8.2 7.6 6.2 6.2 6.8 6.1 5.8 5.7 5.6 5.1 5.2 5.1 4.3 4.0 1–3 Years 5.5 4.7 4.1 4.4 4.1 3.5 3.4 3.3 3.4 3.0 3.1 3.4 3.0 3.4 3.2 3.2 2.9 2.8 3–5 Years 4.3 4.6 4.4 4.6 4.0 4.6 4.7 4.5 4.3 4.2 4.2 3.8 3.5 3.6 3.1 3.5 5–10 Years 4.5 4.4 4.8 4.8 4.7 4.4 4.2 4.3 4 4 3.6 Recipient and donor age below 45 0–1 Year 15.8 14.9 12.3 11.0 11.9 10.7 8.7 7.1 6.3 6.0 7.1 6.3 5.3 5.5 5.9 5.2 5.1 4.6 4.4 4.2 1–3 Years 6.3 5.6 4.6 5.0 4.8 4.1 4.2 4.0 4.3 4.3 4.0 4.3 3.9 4.1 4.5 4.7 3.6 4.0 3–5 Years 5.0 5.4 4.4 5.3 4.2 5.2 5.6 5.5 5.4 5.5 4.7 4.6 4.6 5.1 4.2 4.7 5–10 Years 4.2 4.3 4.7 4.4 4.3 4.3 4 3.8 3.6 3.7 3.3 Nonblack/black 0–1 Year 13.8/21.5 13.6/16.6 11.4/15 10.4/14.2 11.4/13.9 10.1/12.3 7.7/9.6 7/9 6.6/7.9 5.5/7.9 6/8.8 5.2/8.3 4.8/8.1 5.2/6.9 4.7/7.5 4.3/6.8 4.4/6.8 4.6/6.1 3.6/5.9 3.4/5.2 1–3 Years 4.2/9.8 3.4/8.8 2.9/7.8 3.3/7.8 3.1/7.3 2.4/6.4 2.2/6.4 2.3/6.1 2.5/5.8 2.3/4.9 2/5.8 2.4/5.9 2.3/4.6 2.4/5.6 2.3/5.3 2.3/5.2 2/4.8 2/4.3 3–5 Years 3.2/8.7 3.6/8.2 3.3/8.7 3.6/8.2 3.2/6.6 3.7/7.1 7.5/3.8 3.6/7.1 3.4/6.9 3.1/7.2 3.2/6.9 2.9/6.3 2.7/5.6 2.7/5.9 2.4/4.8 3/4.9 5–10 Years 3.7/8.1 3.8/6.9 4.3/6.8 4.1/7.5 4.2/6.5 3.7/6.8 3.4/6.6 3.8/6 3.2/6.5 3.5/5.7 3.1/5 Recipient and donor age below 45 0–1 Year 14.4/20 13.9/17.8 11.3/15 10.1/13.3 11.1/14.2 10.2/11.8 8.2/9.5 5.8/9.8 5.8/7.4 4.9/8.2 5.7/9.8 5.4/7.9 4.9/6.1 5/6.4 5/7.3 7.5/3.9 4.9/5.4 4.4/5 3.5/5.7 3.2/5.7 1–3 Years 4.7/11.5 3.9/10.2 2.9/9.4 3.7/8.2 3.1/9.5 2.9/6.9 2.7/7.3 2.7/6.9 3/6.9 2.9/7.3 2.6/7.2 3/7 2.9/5.7 2.8/6.6 3.2/6.7 3.2/7.5 2.6/5.2 2.7/6 3–5 Years 3.6/10.3 4.6/7.8 2.9/9.3 3.9/9.1 3.3/7.1 4/8.5 4.3/8.5 4.6/7.7 4.2/8 4.2/8.3 3.3/8 3.5/7 2.7/8.5 3.9/7.6 3.