Inequalities in outcomes after kidney transplant failure in the UK

BACKGROUND: Failing transplant management is an international research priority. The Failing Kidney Transplant Outcomes Registry Analysis (FAKTOR) is investigating management and outcomes of kidney transplant failure in the UK. METHODS: A retrospective cohort analysis using UK Renal Registry data on adults (≥18 years) with kidney transplant failure (eGFR < 15ml/min/1.73m2) between 01/2012-12/2021. Treatment status was determined each year post-failure as the first status recorded of: i) re-transplantation, ii) haemodialysis (HD), iii) peritoneal dialysis (PD), iv) death; those alive without changing Kidney Replacement Therapy (KRT) modality classed as v) alive without new KRT, subclassified as vi) managed conservatively if eGFR < 7.5ml/min/1.73 m2 with no future dialysis. Treatment status was determined by one-year post-failure and reported by: age, sex, ethnicity, socioeconomic group, primary renal disease (PRD) and centre type (transplanting/non-transplanting). When applicable, last eGFR pre-dialysis was recorded. Regression models investigated the relationship between patient characteristics and centre type with outcomes: i) treatment status by one-year and ii) pre-dialysis eGFR. RESULTS: We included 5447 patients. By one-year, 47.8% first received HD and 5.2% were pre-emptively re-transplanted. Black and Asian people were less likely to be re-transplanted than White people (Black Relative Risk Ratio (RRR) 0.41, 95% CI 0.20-0.87. Asian RRR 0.57, 0.34-0.96). Males were more likely to be re-transplanted (RRR 1.39, 1.06-1.81) and to receive HD (RRR 1.68, 1.47-1.92). Each quintile increase in deprivation was associated with a 22% lower re-transplantation likelihood (RRR 0.78, 0.71-0.86). Diabetic PRD was associated with higher mortality (RRR 1.97, 1.34-2.88) relative to glomerulonephritis. Median pre-dialysis eGFR was 9.6 ml/min/1.73 m2 (IQR 7.7-11.7) and 7.1% higher in non-transplanting compared with transplanting centres (+7.1%, + 2.6% to +11.9%). CONCLUSIONS: This first nationwide description of outcomes following kidney transplant failure in the UK highlights strong evidence of pre-emptive re-transplantation inequalities, favouring White people, those in less deprived areas and males.