Management of patients with a failed kidney transplant: Dialysis reinitiation, immunosuppression weaning, and transplantectomy

Abstract

The number of patients reinitiating dialysis after a failed transplant increases over time and has more than doubled between the year 1988 and 2010 (an increase from 2463 to 5588). More importantly, patients returning to dialysis have been shown to have a greater than three-fold increase in the annual adjusted mortality rates compared with those with a functioning graft. Continuation of immunosuppression to preserve residual graft function has been implicated to be a contributing factor, seemingly due to immunosuppression-associated cardiovascular and infectious complications and malignancy risk, among others. Nonetheless, maintenance low-dose immunosuppression has been suggested to confer survival benefit in patients returning to peritoneal dialysis. Whether early vs late reinitiation of dialysis or whether transplantectomy has an impact on patient survival remains poorly defined. Consensus guidelines for the management of a failed allograft are lacking. In this article, we present a literature overview on the ideal timing of dialysis reinitiation after graft loss, the management of immunosuppression after graft failure, and the risks and benefits of transplantectomy. The authors' perspectives on the management of this special patient population are also discussed.

Mortality after Renal Allograft Failure and Return to Dialysis

“…Ojo et al [15] reported 5-year patient survival after primary renal allograft failure was 36, 49, and 65% for type I diabetes mellitus (DM), type II DM, and non-diabetic ESRD patients, respectively ( p < 0.001; DM vs. non-diabetics). Close monitoring and management of comorbid disease is essential for risk reduction in these patients [7,9]. The most common causes of death in our study included cardiac and infectious diseases, which is consistent with the current literature [16,17,18,19].…”

“…From 1988 to 2010, the number of patients returning to dialysis after graft failure has more than doubled [7]. Allograft failure is often due to rejection, drug toxicity, and chronic allograft nephropathy [8].…”

Human papillomavirus‐related anogenital premalignancies and cancer in renal transplant recipients: A Danish nationwide, registry‐based cohort study

“…However, in our study, the risk of anogenital premalignancies in male RTRs did not decrease when shifting to dialysis, and female RTRs on dialysis remained at increased risk of vaginal, vulvar and anal premalignancies. This may be because some RTRs continue immunosuppressant treatment when shifting to dialysis to preserve residual graft function or prevent rejection of the failed graft …”

Repeat Kidney Transplantation

“…Если в качестве источника органа для повторной пересадки рассматривается трупный донор и время нахождения пациента в листе ожидания может до-стигать нескольких лет, то целесообразно провести минимизацию, а в дальнейшем и полную отмену иммуносупрессии [51].…”