Care of the Patient after Renal Allograft Failure: Managing the Present and Planning for the Future

Abstract

The number of patients with end-stage renal disease undergoing kidney transplantation – both cadaveric and living-donor – continues to rise. With long-term graft survival relatively fixed, this trend means that increasing numbers of patients are returning to dialysis after graft loss. Most will never be retransplanted, which introduces a host of clinical questions regarding optimal management of this unique patient population. In this paper, we explore data that informs astute care of the patient requiring dialysis after graft loss. We address new data about the increased clinical risk and the optimal dialysis modality in renal allograft loss, explore new approaches to immunosuppression and transfusion management, and examine the risks and benefits of allograft nephrectomy and timing thereof. While there are no randomized clinical trials in this field, rapidly evolving data will aid the clinician whose practice includes patients who have been transplanted and are returning to dialysis.

Development and evaluation of dedicated low clearance transplant clinics for patients with failing kidney transplants

“…This translates into disparate management guidelines for transplant clinicians in how to deal with failing or failed kidney transplants (Pham et al 2015). These are important issues to investigate as failed kidney transplants are associated with an increased risk of cardiovascular and infection-related death for RFKTs as allograft function declines (Fuquay & Teitelbaum 2012). In addition, once the kidney allograft has failed, there is a significant mortality risk for kidney transplant recipients once they return to dialysis as their form of renal replacement therapy (Gill et al 2002a).…”

Management considerations in the failing renal allograft

“…Loss of residual renal function occurs much more quickly in DAGL patients compared with incident PD patients and this can make planning dialysis initiation difficult . Importantly, a more rapid loss of residual kidney function in the absence of immunosuppression could compromise PD adequacy and necessitate a change to HD . A decision analysis model in transplant recipients has suggested a small survival benefit from continuing immunosuppression when returning to peritoneal dialysis in patients with a residual glomerular filtration rate (GFR) >15 mL/min, although several important assumptions have been made in this analysis .…”

Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers

“…Patients face a higher risk of morbidity and mortality in addition to depression and social challenges during the transition period when immunosuppresion is not well monitored. 2 The estimated mortality rate in patients with failed allograft is 16% in the first year following allograft failure with persistently increased risk compared to those starting dialysis without a prior failed transplant. 3,4 Two major causes of mortality after returning to dialysis are infections and cardiovascular disease.…”