What happens after graft loss? A large, long‐term, single‐center observation

Abstract

Summary The number of patients returning to dialysis after graft failure increases. Surprisingly, little is known about the clinical and immunological outcomes of this cohort. We retrospectively analyzed 254 patients after kidney allograft loss between 1997 and 2017 and report clinical outcomes such as mortality, relisting, retransplantations, transplant nephrectomies, and immunization status. Of the 254 patients, 49% had died 5 years after graft loss, while 27% were relisted, 14% were on dialysis and not relisted, and only 11% were retransplanted 5 years after graft loss. In the complete observational period, 111/254 (43.7%) patients were relisted. Of these, 72.1% of patients were under 55 years of age at time of graft loss and only 13.5% of patients were ≥65 years. Age at graft loss was associated with relisting in a logistic regression analysis. In the complete observational period, 42 patients (16.5%) were retransplanted. Only 4 of those (9.5%) were ≥65 years at time of graft loss. Nephrectomy had no impact on survival, relisting, or development of dnDSA. Patients after allograft loss have a high overall mortality. Immunization contributes to long waiting times. Only a very limited number of patients are retransplanted especially when ≥65 years at time of graft loss.

Significance of HLA-DQ in kidney transplantation: time to reevaluate human leukocyte antigen–matching priorities to improve transplant outcomes? An expert review and recommendations

“…Kidney transplantation is a standard of care treatment for patients with kidney failure, with over 75,000 kidney transplants performed annually around the globe (1,2). Unfortunately, while kidney graft survival increased significantly over the years, many patients lose their life-saving transplant and face return to dialysis, and potentially the gift of another kidney transplant (3). The shortage of kidneys for transplantation, the medical and financial ramifications associated with the need to treat allograft rejection, and the impact of immunosuppression, graft dysfunction / loss on patient quality of life, all highlight an unmet need for improving kidney transplant outcomes that must be addressed.…”

“…Importantly, over half of the longterm kidney graft failure can be attributed to DSA-mediated chronic rejection (27). It has been shown that up to 30% of non-sensitized kidney transplant recipients develop de novo DSA within 10 years from transplantation and about 40% of patients lose their grafts within 5 years of development of de novo DSA (28)(29)(30).…”

“…A single centre study (36) demonstrated that the risk of sensitization after failure of a first kidney transplant increases incrementally with the number of HLA mismatches in HLA-A, -B, DR and -DQ loci. This can have a profound impact on the likelihood of finding a second, antibody-compatible, kidney donor (30). It is important to emphasize that the perils of sensitization following the first transplant are worse in the pediatric and young-adult population as these patients are more likely to require more than one additional transplant in their lifetime.…”

Rationale for Surrogate Endpoints and Conditional Marketing Authorization of New Therapies for Kidney Transplantation

“…In addition, increased morbidity and inferior outcomes after re-transplantation can result from diverse complications such as long waiting times, increased doses of immunosuppressive therapy, increased risk of infections and malignancies, high rates of acute rejection, and delayed graft function. Kidney graft failure is also associated with increasing the average waiting time for transplantation, due to relisting ( 15 ).…”

“…A publication from Charité Hospital in Berlin found that between 1997 and 2017, 267 graft losses occurred in 254 patients, resulting in 117 (43.8%) relistings ( 21 ), of whom only 42 (35.9%) patients received a second transplant. At 5 years after graft loss, of the 254 patients, 49% had died, 27% were relisted, 14% were on dialysis and not relisted, and only 11% were re-transplanted ( 15 ).…”