Transplantation Improves Patient Survival in a PD-first Program in South Africa.

Background: There are limited data on kidney replacement therapy (KRT) allocation and outcomes in patients in kidney failure (KF) who access public healthcare in South Africa. Methods: This retrospective cohort study included patients referred for KRT at the time of KF diagnosis. Incident KF cases were identified between 2012 and 2020, followed from referral until death, kidney transplantation, or continued waitlisting at study end (December 31, 2023). Descriptive analyses and comparisons were performed between KRT allocation and outcomes. Time-to-event analyses employed competing risk models to estimate cumulative incidence functions, whereas Kaplan-Meier methods were applied to calculate survival probabilities. Results: Overall, 761 patients were referred with KF, of which 598 (79%) were untreated and presumed to have died. Untreated patients were either not considered at referral (n = 432), or not accepted at KRT committee meeting (n = 175) because of policy-driven factors. Of those presented to the KRT committee (n = 338), 48% (n = 163) were accepted onto the dialysis program and waitlisted for transplantation. Accepted patients were younger and had greater medical stability and socioeconomic circumstances compared with non-accepted patients. Only 21% (n = 34) of patients initiated on dialysis were transplanted. At 5 y post-KRT initiation, there was a greater probability of dying on the waitlist compared with receiving a transplant (cumulative incidence function 35% [95% CI, 27-42] versus 18% [95% CI, 13-25]), and post-transplantation survival was significantly greater than pre-transplant survival (100% versus 61% [95% CI, 53-69]). Conclusions: Our study findings align with the challenges of providing dialysis and transplantation in a lower- to middle-income setting where patients were most often precluded from KRT because of poorly controlled comorbidities or a lack of unit capacity. There was a clear survival advantage in patients who were transplanted over those who remained on dialysis; however, transplant services remain limited.