During the 2.5 to 7.5 years of follow-up, 54 (26%) of the 209 patients died. In 30 (56%) of the 54 deaths, autopsy reports were available for the purpose of establishing the cause of death; in the remaining 24 deaths, cause of death was determined on clinical grounds. The mortality rate for related kidney recipients was 43 of 128 (34%). The mortality rate for patients who received a primary graft and at least one retransplant during the study period was 12 of 44 (27%). The mortality rate for diabetic patients was 11 of 22 (50%). The mortality rate for splenectomized patients was 24 of 101 (24%); 77 of 155 (50%) of the survivors had undergone splenectomy and 24 of 54 (44%) of the patients who died had undergone splenectomy.
Graft function, as of 1982 for survivors and just before terminal events for patients who died, is outlined in . As of February 1982, 46 of 155 (30%) of the survivors were again undergoing dialysis; 101 of 155 (65%) of the survivors had functioning grafts with serum creatinine levels of 2.0 mg/dL or less; 8 of 155 (5%) had serum creatinine levels greater than 2.0 mg/dL. Among the patients who died, the grafts had already failed in 19 (35%) of the 54 patients; these patients had returned to chronic hemodialysis before the onset of their terminal illness or terminal event. Twenty-two (41%) of the patients who died had serum creatinine levels of 2.0 mg/dL or less, and 13 (24%) had functioning grafts, with serum creatinine levels greater than 2.0 mg/dL.
The causes of death and the time intervals between first transplantation and death are listed in . Death occurred from nine days to 59 months after first transplantation. The causes of death were infection in 22 of 54 patients (41%), cardiovascular disease in 11 of 54 patients (20%), suicide in 8 of 54 patients (15%), gastrointestinal (GI) tract problems in 7 of 54 patients (13%), malignant neoplasms in 2 of 54 patients (4%), and miscellaneous causes in 4 of 54 patients (7%). Eighteen (33%) of the 54 deaths occurred within the first three months after primary transplantation; ten (19%) of the 54 deaths occurred between four and 12 months after transplantation; and 26 (48%) of the 54 deaths occurred more than one year after the primary transplant. The illustrates actuarial patient survival for all 209 patients, as well as the subgroups of 128 cadaver-graft recipients and 81 related-graft recipients. The actuarial results were calculated using the method of Merrill and Schulman.8
The period of greatest risk of death was the first six months after transplantation; but even after this interval, there was a continuing threat to life.
Fig 1 Actuarial patient survival for 209 patients who received kidney transplants between September 1974 and August 1979. Five-year actuarial patient survival was 86% for recipients of living-related donor (LRD) kidneys (N=81) and 64% for recipients of cadaver (more ...)
Death From Infection
Overwhelming infection was the primary cause of death in 22 patients, of whom five were diabetic. Death occurred nine to 59 months after transplant (mean, 13.6 months), and 16 of these had functioning transplants at the time of death.
The most common clinical picture of sepsis, occurring nine days to 14 months after surgery (mean, six months) in 11 patients was refractory pneumonia with respiratory failure. Eight of these patients had functioning transplants (six, first; two, second), and six patients had serum creatinine levels less than 2.0 mg/dL. In four patients, it was not possible to identify the dominant organism. In others, a variety of organisms was isolated, including Pneumocystis carinni (four patients), cytomegalovirus (CMV) (three patients), Aspergillus (one patient), Cryptococcus (one patient), and Nocardia (one patient). In addition, two patients had systemic sepsis caused by Staphylococcus plus Pseudomonas and Staphylococcus plus Klebsiella.
Fatal pneumococcal septicemia occurred in three patients at 12, 22, and 59 months (mean, 31 months), all of whom had previously undergone splenectomy. One of these patients, a child who received a transplant for oxalosis and had otitis media develop, has been described elsewhere.9
All three had functioning transplants, and two had excellent long-term function of their primary graft; all three were in good stable condition until hours or a few days before death.
Four diabetic patients had sepsis from soft-tissue infections; three of these arose in the extremities five, ten, and 20 months after transplant. The fourth patient died of overwhelming Serratia sepsis 24 days after transplant. Three of the four patients had returned to dialysis before the onset of their terminal illness. One patient had good graft function at the time of death.
Four other nondiabetic patients died of sepsis caused by staphylococcal bacterial endocarditis, intraabdominal abscess of uncertain cause, enterobacterial septicemia, and infected arteriovenous fistula (one patient each).
Infection was a contributory but not primary cause of death in another nine patients. Five patients had pneumonia with single or multiple organisms (Pneumocystis, CMV, Nocardia, Aspergillus, unknown); four had peritoneal sepsis with or without systemic infection (Staphylococcus, Candida, Klebsiella) in association with GI tract perforations.
Death From Cardiovascular Causes
Five patients (mean age at transplant, 47 years; range, 40 to 58 years) died of myocardial infarction at 1, 2, 13, 25, and 32 months after surgery. Three more patients died of pulmonary emboli. (One other patient had an undetected myocardial infarction discovered incidentally at autopsy, and pulmonary emboli were seen in the lungs of several additional patients who underwent autopsy.)
One diabetic patient suffered a cardiac arrest on dialysis 46 months after transplant, and one severely hypertensive patient with satisfactory renal function 32 months after transplant was dead on arrival at the hospital and was presumed to have had a myocardial infarction. One patient died of congestive heart failure while receiving dialysis at another center 23 months after transplant.
All 11 patients dying of cardiovascular causes were at least 40 years of age (mean, 49 years; range, 40 to 60 years) at the time of transplantation. Four of these patients had returned to dialysis, and only four had serum creatinine levels of 2.0 mg/dL or less. Three were diabetic.
Death From Suicide
Eight younger patients (mean age at transplant, 27.8 years; range, 17 to 38 years) died as a result of overt or veiled suicide, including refusal to undergo dialysis after unsuccessful transplantation. Most had recognizable psychological instability before transplantation and all but one had rejected one or more transplants. One 26-year-old woman who appeared to have been rehabilitated and who had perfect renal function after primary HLA-identical-related transplantation shot herself five months after surgery. The remaining seven patients survived from one to 29 months after graft failure and return to dialysis. Only one patient had a protracted hospital course with multiple retransplants. Two of the patients who died of suicide were diabetic.
Death From GI Tract Causes
Seven patients died of GI tract disorders; most of these deaths were complicated by sepsis. The mean age at the time of transplantation for this group was 36.5 years (range, 35 to 50 years), and none of the patients were diabetic.
Perforations of the GI tract from duodenal ulcer, gastric ulcer, small bowel, and sigmoid colon, were each responsible for the death of one patient. These four patients died of peritonitis, with or without abscess formation, despite early diagnosis and aggressive surgical management. Additional contributing causes were Nocardia pneumonia and pulmonary emboli in one patient and Klebsiella septicemia in another patient.
Severe acute pancreatitis one month after transplantation was responsible for the death of a 35-year-old woman; a 35-year-old man died 42 months after transplantation from rupture of a pancreatic abscess.
One 47-year-old man with a history of ulcer disease manifested duodenal ulceration one month after transplantation, and, despite truncal vagotomy and antrectomy after an initial hemorrhage, exsanguinated one week later. His course was complicated by a combined Aspergillus and CMV pneumonia, and a silent myocardial infarction was found at autopsy.
Death From Malignant Neoplasms
Two patients, 48 and 50 years old at the time of transplantation, died of malignant neoplasms—one of undifferentiated sarcoma of the bone marrow (which could not be more precisely characterized), 19 months after transplant, and one of diffuse lymphoma originating in deep cervical lymph nodes, 40 months after transplant. Both patients had functioning first grafts and had not received unusual amounts of immunosuppressive drugs, although the former patient was treated for a mild rejection episode just before the diagnosis of a malignant neoplasm.
Death From Miscellaneous Causes
There were four deaths from other causes; three occurred within the first three months after surgery and were related to technical complications. A 20-year-old man died of aspiration 13 days after transplant after anesthesia for evacuation of a small peritransplant hematoma. A 53-year-old man with a severe pneumonia, the cause of which was never determined, died of hemorrhage after transbronchial lung biopsy. Both had functioning first transplants. A 22-year-old man with CMV pneumonia and hepatitis died of hemorrhage after a percutaneous liver biopsy three months after transplant, with excellent renal function. One diabetic patient, who had poorly controlled diabetes on dialysis after a rejected transplant, died after a hypoglycemic seizure at another hospital 29 months after transplantation.