Outcomes following dialysis and transplantation in amyloidosis: ANZDATA analysis

Abstract Background The kidneys are frequently affected by systemic amyloidosis. Despite this, contemporary survival outcomes for patients reaching kidney failure due to amyloidosis remain poorly defined relative to other causes of kidney failure. This study aims to characterise patient survival with renal amyloidosis requiring kidney replacement therapy (KRT) and directly compare these outcomes with diabetic nephropathy, glomerular disease, and polycystic kidney disease (PKD). Methods This was a retrospective cohort study using the Australia and New Zealand Dialysis and Transplant Registry for patients who initiated KRT between 1990 and 2022. A propensity-matched analysis was performed at 1:4 ratio for amyloidosis versus PKD, glomerular disease and diabetes. Patients were matched for age, sex, treatment era, comorbidities and dialysis vintage. Kaplan-Meier survival curves and Cox proportional hazards were used to compare patient survival on dialysis and post-transplant. Results 84,148 incident dialysis patients were included, of which 654 (0.8%) had kidney failure attributed to amyloidosis. Using amyloidosis as the reference group, matched comparator cohorts had lower mortality hazards: diabetic nephropathy (HR 0.68, 95% CI 0.62–0.74), glomerular disease (HR 0.38, 95% CI 0.34–0.42), and PKD (HR 0.28, 95% CI 0.26–0.32). 23,463 incident transplant recipients were included, of which 48 (0.2%) had kidney failure secondary to amyloidosis. Using amyloidosis as the reference group, post-transplant mortality hazards were similar for T2DM (HR 1.00, 95% CI 0.75–1.35), but lower for T1DM (HR 0.72, 95% CI 0.52–0.98), glomerular disease (HR 0.40, 95% CI 0.28–0.57), and PKD (HR 0.38, 95% CI 0.29–0.56). Amyloidosis subtype data were unavailable, limiting assessment of disease-specific outcomes. Conclusions Kidney failure due to amyloidosis was associated with markedly worse survival on dialysis and less favourable post-transplant patient survival compared with several comparator kidney diseases. However, death-censored graft survival appeared broadly comparable, suggesting that excess post-transplant risk is largely driven by patient mortality rather than intrinsic graft failure.