Infections After Renal Allograft Failure in Patients With or Without Low-Dose Maintenance Immunosuppression1

Abstract

The increase in serious and life-threatening infections associated with even low-dose immunosuppression argues in favor of discontinuation of these drugs. The removal of failed renal allografts should be considered.

Predictors of Mortality in Patients Returning to Dialysis after Allograft Loss

“…Immunosuppressants are administered to patients after graft loss in order to preserve residual renal function and prevent allograft rejection. However, prolonged immunosuppression is suspected to increase the risk of infection, malignancy, and cardiovascular morbidity [15,16] . Although beneficial effects, such as erythropoietin production, and the risk of surgical complications have been proposed as reasons to maintain failed grafts, it has been suggested that failed grafts are a cause of chronic inflammation which in turn worsens malnutrition and raises the risk of cardiovascular events [17][18][19] .…”

Nephrectomy After Transplant Failure: Current Practice and Outcomes

“…1 Percentages are shown unless otherwise indicated. 2,3,4,5,6,7 Data were available for 73%, 79%, 59%, 82%, 82%, 93%, of patients, respectively. 8 Defined by the need for dialysis prior to discharge from hospital after transplantation.…”

“…The role of transplant nephrectomy in the management of transplant failure patients has only been examined in small single center studies (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15). Some investigators have advocated against the removal of the asymptomatic failed allograft due to the morbidity and mortality associated with transplant nephrectomy (9,12).…”

“…Some investigators have advocated against the removal of the asymptomatic failed allograft due to the morbidity and mortality associated with transplant nephrectomy (9,12). Others have contended that the failed allograft is a source of sepsis (4) or chronic inflammation that may lead to complications such as erythropoietin resistance (8), and therefore, should be routinely removed. The high rate of morbidity and mortality among the transplant failure population has been highlighted in a number of recent publications (16)(17)(18)(19)(20)(21)), yet there is relatively little known about the factors that contribute to the poor outcomes of this population.…”

Does Allograft Failure Impact Infection Risk on Peritoneal Dialysis

“…Sasal et al (5) showed increased infectious morbidity in PD patients with prior allograft failure compared with an age-and diabetes-matched cohort of transplant naive PD patients. Several authors report greater morbidity due to infection in PD patients maintained on immunosuppression after transplant failure (6)(7)(8). In contrast, a large study using data from the Australia and New Zealand Dialysis and Transplant Registry found no difference in peritonitisfree survival between transplant failure and transplant naive patients initiating PD (9).…”