Clinical Outcomes after Failed Renal Transplantation—Does Dialysis Modality Matter?

Abstract

Patients returning to dialysis after graft loss (DAGL) are an increasing segment of the end-stage renal disease (ESRD) population. It is unclear whether patients with previous graft loss have equivalent or reduced survival from the time of restarting dialysis when compared with ESRD patients initiating dialysis for the first time. Moreover, the impact of dialysis modality on the survival of patients returning to DAGL is not known. Studies of patients with transplant graft failure returning to hemodialysis (HD) have suggested decreased survival when compared with transplant-naïve dialysis patients, yet some studies of patients with graft failure returning to peritoneal dialysis (PD) have demonstrated equivalent survival. Based on these data, it is unclear whether survival differences may exist between the dialysis modalities, and if they do, whether they can be attributed to either differences in patient characteristics or to factors related to the dialysis modalities. For patients starting back onto dialysis, in whom preservation of residual renal function is important, it is also unclear how immunosuppression reduction or transplant nephrectomy may affect survival. In this review, we will summarize the available literature on survival rates of patients returning to DAGL; compare and contrast survival after initiation of HD and PD and discuss what is known about the impact of transplant nephrectomy and the different approaches to immunosuppression reduction. Practical considerations will be discussed with a specific emphasis on patients treated by PD.

Role of allograft nephrectomy following kidney graft failure: preliminary experience with pre-operative angiographic kidney embolization

“…kidney transplants (KT) fail each year and 20 % of patients on the kidney waiting list have had a previous failed KT [1][2][3]. Previous studies have reported that 25 to 50 % of surviving patients with kidney graft failure (GF) eventually undergo allograft nephrectomy (AN) [4][5][6][7][8][9].…”

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

“…Due to an absence of clear data on the subject, guidelines for which patients should undergo allograft nephrectomy, and at what time relative to resumption of dialysis, are lacking [35]. The potential benefits of allograft nephrectomy include removal of several harmful factors: a nidus of inflammation, the need for immunosuppression, and the presence of antigens that will raise the PRA over time and endanger future transplantation.…”

Dialysis Survival after Graft Loss

“…Again, studies have offered differing results when comparing survival outcomes of DAGL with transplant-naive patients on dialysis, depending on the specific cohorts studied and the duration of follow-up (6,7). In the majority of the studies, patients who commenced PD after graft loss experienced outcomes comparable to those with failed native kidneys (8,9). Differences in survival between PD and HD in DAGL patients has not been rigorously examined.…”