Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Nephrol. May 6, 2015; 4(2): 148-159
Published online May 6, 2015. doi: 10.5527/wjn.v4.i2.148
Management of patients with a failed kidney transplant: Dialysis reinitiation, immunosuppression weaning, and transplantectomy
Phuong-Thu Pham, Matthew Everly, Arman Faravardeh, Phuong-Chi Pham
Phuong-Thu Pham, Arman Faravardeh, Department of Medicine, Nephrology Division, Kidney Transplant Program, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
Matthew Everly, Terasaki Foundation Laboratory, Los Angeles, CA 90025, United States
Phuong-Chi Pham, Department of Medicine, Division of Nephrology and Hypertension, UCLA-Olive View Medical Center, Sylmar, CA 91342, United States
Author contributions: All authors contributed to this paper.
Conflict-of-interest: The authors declare no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Phuong-Thu Pham, MD, Department of Medicine, Nephrology Division, Kidney Transplant Program, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States.
Telephone: +1-310-7941757
Received: June 15, 2014
Peer-review started: June 15, 2014
First decision: July 10, 2014
Revised: January 24, 2015
Accepted: January 30, 2015
Article in press: February 2, 2015
Published online: May 6, 2015

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.

Keywords: Failed kidney transplant, Allosensitization, Immunosuppression weaning, Allograft nephrectomy, Transplantectomy, Dialysis reinitiation after transplant failure

Core tip: The number of patients with a failed allograft returning to dialysis increases over time. Studies suggest that such patients are at increased morbidity and mortality risks compared with their transplant-naïve, incident dialysis patients. This review provides a critical literature overview of the risks and benefits of early vs late dialysis re-initiation, immunosuppression weaning, and transplantectomy in patients with a failed allograft. Based on currently available literature, suggested guidelines for the management of this unique patient population are presented.