Survival and Access to Kidney Transplantation of High-Urgent Patients Due to Vascular Access Failure

Introduction: Total and permanent lack of access to dialysis was considered a high-urgency (HU) candidate for transplant, as established by the Brazilian kidney allocation system. This procedure allows them to receive the first ABO-compatible and negative T and B-cell CDC-CM kidney. We aimed to compare the survival on the WL and the access to transplant between HU patients and non-HU candidates. Methods: This observational, retrospective study included 22,545 adult kidney transplant candidates listed in the state of São Paulo, from January 2010 to December 2018, and analyzed until December 2019; follow-up time was 27 months. Seven hundred and eighty-eight (3.5%) patients were considered HU. Results: Most of the WL were male (59%), mean age of 51 years (± 20), and non-sensitized (70%); 1,301 (5.8%) were previously transplanted. Compared to the non-HU, the HU group was younger, mostly female, more previously transplanted, and more sensitized: panel reactive antibody (PRA) 11-85% (24% vs. 17%; p < 0.001) and PRA > 85% (14% vs. 7.8%; p < 0.001). Diabetes (odds ratio [OR] 1.988; p = 0.000) and PRA > 85% (OR 1.9; p = 0.000) were risk factors for death, mainly in HU patients (diabetes: OR 2.39; p = 0.045/PRA > 85%: OR 15.06; p = 0.000). Age was a risk factor for death in non-HU, with worse outcomes in the 51-60 years group (OR 2.72; p = 0.000) and the > 60 years group (OR 4.3; p = 0.000). Patients with chronic glomerulonephritis were transplanted more frequently in both groups (OR 3.8 vs. 1.8; p = 0.000). The HU group received more transplants (88% vs. 40%, p = 0.000), had lower mortality (7% vs. 19%; p = 0.000), and spent less time on the list (5% vs. 41%; p = 0.000). Sensitized were more difficult to transplant, even in the HU group (PRA 51-85%: OR NP 0.54 vs. P 0.43; p = 0.008/PRA > 85%: OR NP 0.19 vs. P 0.06; p = 0.000). Conclusion: Elderly, diabetic, and sensitized patients had worse results on the list. Giving urgency to patients with dialysis access failure allowed better survival, greater and faster access to transplantation, except if PRA > 50%.