Renal replacement therapy after kidney graft loss: redefining the role of peritoneal dialysis.

Introduction: The role of peritoneal dialysis (PD) after kidney transplant (KT) failure is not well established.Methods: We conducted a retrospective analysis of all KT recipients in Andalusia (1978-2023) who resumed dialysis after graft loss. Patients were stratified by dialysis modality-hemodialysis (HD) or PD-and clinical characteristics and outcomes were compared. Preemptive re-transplantation cases were excluded. A second analysis compared PD patients with and without prior KT. Predictors of mortality and technique failure were identified through multivariate Cox regression. Results: Of 11,718 KT recipients, 2,536 (21.6%) resumed dialysis after first graft loss: 2,253 started HD and 201 PD; 82 underwent preemptive re-KT. PD patients were younger (p < 0.001), more frequently had glomerular disease (p = 0.038), and often had prior PD before KT (52.7% vs 8.1%; p < 0.001). Patient survival was similar between modalities (p = 0.256). Multivariate analysis identified age, male sex, and diabetes mellitus (DM) as mortality predictors, but not dialysis modality. When comparing post-KT PD patients (n = 201) to de novo PD patients (n = 5312), the former were younger (p < 0.001), remained longer on PD (p = 0.003), and more often withdrew due to re-transplantation (p = 0.002). Peritonitis rates were comparable between groups. Technique survival at 1 and 5 years was comparable (post-KT: 79% and 37.4%; non-KT: 78.2% and 38.6%; p = 0.359). Male sex and DM were associated with reduced technique survival, but prior KT status was not. Conclusions: In conclusion PD after KT failure is a safe and effective modality, with similar survival and technique outcomes to de novo PD, supporting its broader implementation in post-transplant care.