Abstract：
OBJECTIVE: It is unclear whether kidney transplant candidates with diabetes have equitable transplantation opportunities or have divergent survival probabilities stratified by kidney replacement therapy. The aim of this study was to investigate these two issues using national transplant registry data in the UK.
METHODS: A cohort study was undertaken of prospectively collected registry data of all wait-listed people with kidney failure receiving dialysis in the UK. All people listed for their first kidney-alone transplant between 2000 and 2019 were included. Stratification was done for cause of kidney failure. Primary outcome was all-cause mortality. Time-to-death from listing was analysed using adjusted non-proportional hazard Cox regression models, with transplantation handled as a time-dependent covariate.
RESULTS: A total of 47,917 wait-listed people with kidney failure formed the total study cohort, of whom 6594 (13.8%) had diabetes classified as cause of kidney failure. People with kidney failure with diabetes comprised 27.6% of the cohort (n=3681/13,359) that did not proceed to transplantation vs only 8.4% (n=2913/34,558) of the cohort that received a transplant (p<0.001). Kidney transplant candidates with diabetes were more likely to be older, of male sex and of ethnic minority background compared with those without diabetes. In an adjusted analysis, compared with remaining on dialysis, any kidney transplant provided survival benefit for wait-listed kidney transplant candidates regardless of diabetes as cause of kidney failure (RR 0.26 [95% CI 0.25, 0.27], p<0.001).
CONCLUSIONS: Kidney transplant candidates with diabetes have a lower chance of transplantation despite better survival after kidney transplantation vs remaining on dialysis. The reasons for this require further investigation to ensure equal transplantation opportunities.
METHODS: A cohort study was undertaken of prospectively collected registry data of all wait-listed people with kidney failure receiving dialysis in the UK. All people listed for their first kidney-alone transplant between 2000 and 2019 were included. Stratification was done for cause of kidney failure. Primary outcome was all-cause mortality. Time-to-death from listing was analysed using adjusted non-proportional hazard Cox regression models, with transplantation handled as a time-dependent covariate.
RESULTS: A total of 47,917 wait-listed people with kidney failure formed the total study cohort, of whom 6594 (13.8%) had diabetes classified as cause of kidney failure. People with kidney failure with diabetes comprised 27.6% of the cohort (n=3681/13,359) that did not proceed to transplantation vs only 8.4% (n=2913/34,558) of the cohort that received a transplant (p<0.001). Kidney transplant candidates with diabetes were more likely to be older, of male sex and of ethnic minority background compared with those without diabetes. In an adjusted analysis, compared with remaining on dialysis, any kidney transplant provided survival benefit for wait-listed kidney transplant candidates regardless of diabetes as cause of kidney failure (RR 0.26 [95% CI 0.25, 0.27], p<0.001).
CONCLUSIONS: Kidney transplant candidates with diabetes have a lower chance of transplantation despite better survival after kidney transplantation vs remaining on dialysis. The reasons for this require further investigation to ensure equal transplantation opportunities.
摘要：
目的：目前尚不清楚糖尿病肾移植患者是否具有公平的移植机会，或通过肾脏替代疗法分层后具有不同的生存概率。这项研究的目的是使用英国的国家移植登记数据调查这两个问题。
方法：对在英国接受透析的所有等待上市的肾衰竭患者的前瞻性登记数据进行队列研究。包括2000年至2019年首次肾脏移植的所有患者。对肾衰竭的原因进行分层。主要结果是全因死亡率。使用调整后的非比例风险Cox回归模型分析了从上市到死亡的时间，移植作为时间依赖性协变量处理。
结果：共有47,917名等待上市的肾衰竭患者组成了整个研究队列，其中6594人(13.8%)患有被列为肾衰竭原因的糖尿病。患有糖尿病的肾衰竭患者占未进行移植的队列的27.6％（n=3681/13,359），而接受移植的队列中只有8.4％（n=2913/34,558）（p<0.001）。患有糖尿病的肾移植候选人更有可能年龄较大，与没有糖尿病的人相比，男性和少数民族背景。在调整后的分析中，与保持透析相比，无论糖尿病是肾衰竭的原因，任何肾脏移植都能为等待上市的肾脏移植候选人提供生存益处(RR0.26[95%CI0.25,0.27]，p<0.001)。
结论：尽管肾移植后的存活率比透析后的存活率更高，但糖尿病肾移植患者的移植机会更低。其原因需要进一步调查，以确保平等的移植机会。
方法：对在英国接受透析的所有等待上市的肾衰竭患者的前瞻性登记数据进行队列研究。包括2000年至2019年首次肾脏移植的所有患者。对肾衰竭的原因进行分层。主要结果是全因死亡率。使用调整后的非比例风险Cox回归模型分析了从上市到死亡的时间，移植作为时间依赖性协变量处理。
结果：共有47,917名等待上市的肾衰竭患者组成了整个研究队列，其中6594人(13.8%)患有被列为肾衰竭原因的糖尿病。患有糖尿病的肾衰竭患者占未进行移植的队列的27.6％（n=3681/13,359），而接受移植的队列中只有8.4％（n=2913/34,558）（p<0.001）。患有糖尿病的肾移植候选人更有可能年龄较大，与没有糖尿病的人相比，男性和少数民族背景。在调整后的分析中，与保持透析相比，无论糖尿病是肾衰竭的原因，任何肾脏移植都能为等待上市的肾脏移植候选人提供生存益处(RR0.26[95%CI0.25,0.27]，p<0.001)。
结论：尽管肾移植后的存活率比透析后的存活率更高，但糖尿病肾移植患者的移植机会更低。其原因需要进一步调查，以确保平等的移植机会。
