Kidney Transplantation for Lithium Nephrotoxicity is Associated With Noninferior Graft and Patient Survival: A National Donor-Stratified Registry Analysis.

INTRODUCTION

To evaluate donor-stratified graft and patient survival following kidney transplantation (KT) for lithium-associated end-stage kidney disease (ESKD).

METHODS

This retrospective analysis utilized the Organ Procurement and Transplantation Network database. Adult KT recipients (January 1, 2015-December 30, 2024) with lithium-associated nephrotoxicity as the primary listing diagnosis (n = 840) were compared with those transplanted for other etiologies. Deceased-donor (DDKT; n = 584) and living-donor (LDKT; n = 256) cohorts were propensity matched 1:1 within donor type. Gompertz parametric survival models were selected after proportional hazards violation.

RESULTS

Median follow-up was 851 days (DDKT) and 1262 days (LDKT). Matched DDKT recipients with lithium-associated ESKD had a lower prevalence of body mass index greater than 35 kg/m2 (16.8% vs. 21.3%, p = 0.047), lower calculated panel reactive antibody (17.45 ± 30.58 vs. 27.85 ± 37.48, p < 0.001) and lower private insurance coverage (20.4% vs. 27.9%, p = 0.003). Lithium toxicity independently predicted reduced graft failure (HR, 0.668; 95% CI, 0.490-0.912; p = 0.011) and mortality (HR, 0.667; 95% CI, 0.483-0.921; p = 0.014). No other covariate retained independent significance in the adjusted model. Lithium-associated ESKD did not predict graft failure or mortality among LDKT recipients.

CONCLUSION

KT for lithium-associated ESKD was not associated with inferior outcomes. The favorable survival signal was confined to DDKT. It was more likely attributable to recipient-level phenotypic differences and donor-risk context than to any protective property of the underlying diagnosis. Posttransplant lithium dosing, compliance and rechallenge data are not captured in registry data and remain unmeasured.