Copyright ©The Author(s) 2015.
World J Nephrol. May 6, 2015; 4(2): 148-159
Published online May 6, 2015. doi: 10.5527/wjn.v4.i2.148
Table 1 Continuation of immunosuppression after a failed transplant
Potential beneficial effectsPotential adverse effects
Preservation of residual kidney functionMetabolic complications (diabetes, hypertension, dyslipidemia)
Decreased incidence of graft intolerance syndrome and the need for allograft nephrectomySteroid-associated adverse effects (e.g., diabetes, cataracts, myopathy, and avascular necrosis among others)
Minimization of allosensitizationCardiovascular complications
Avoidance of overt acute rejectionIncreased susceptibility to infection
Prevention of adrenal insufficiency syndromeMalignancy (especially skin cancers, Kaposi’s sarcoma, non-Hodgkin’s lymphoma, and lip cancers)
Prevention of reactivation of systemic disease (e.g., systemic lupus erythematosus, vasculitis)Costs (particularly when data supporting continued immunosuppression are lacking)
Table 2 Categorization of cancers in the end-stage kidney disease population
Urinary tract
Immune-deficiency relatedHodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Melanoma of skin
Kaposi’s sarcoma
Carcinoma of
Mouth, tongue, tonsil, oropharynx
Cervix, uteri, vagina, vulva
Eye, squamous cell carcinoma only
Not-related toRectum
immune deficiencyBreast
Of uncertain statusAll other cancers
Table 3 Transplantectomy: Potential risks and benefits and impact on a repeat transplant
Potential benefits
A failing graft is a focus of a chronic inflammatory state
May reduce mortality ratesVariable results, further studies are needed
Potential adverse effects
Residual kidney function may allow less stringent fluid restriction
Surgery-related morbidity and mortalityMorbidity 17%-60% in most series reported
Mortality 1.5%-14% in most series reported
Allosensitization and the potential for future prolonged wait-times for a compatible crossmatch kidney
Impact on a repeat transplant
Mixed reports due to potential confounding factors
Differences among studies in:
Immunosuppression withdrawal protocols
Recipient and donor demographics
Era of transplantation
Indications for transplantectomy
Time on dialysis prior to a repeat transplant
Causes of prior graft loss
Allosensitization associated with blood transfusion
Pre-existing DSA with or without complement-fixing DSA (see text)
HLA matching of subsequent graft
Donor type (living vs deceased)
Table 4 Suggested immunosuppression withdrawal protocols based on maintenance therapy
CNI + antimetabolitea + prednisoneCNI + mTOR inh + prednisonemTOR inh + prednisone
Discontinue antimetabolite at initiation of dialysisDiscontinue mTOR inh at initiation of dialysisTaper mTOR inh over 4-6 wkb
Taper CNI overTaper CNI overMaintain same steroid dose at initiation of dialysis x 2-4 wk, then taper by 1 mg/mo (starting from 5 mg daily) until off
4-6 wkb4-6 wkb
Maintain same steroid dose at initiation of dialysis x 2-4 wk, then taper by 1 mg/mo (starting from 5 mg daily) until offMaintain same steroid dose at initiation of dialysis x 2-4 wk, then taper by 1 mg/mo (starting from 5 mg daily) until off
Table 5 Absolute and relative indications for transplantectomy
Absolute indications (commonly accepted)Relative indications (controversial)
Primary nonfunction Hyperacute rejection Early recalcitrant acute rejection Early graft loss (generally defined as graft loss within the first year) Arterial or venous thrombosis Graft intolerance syndrome Recurrent urinary tract infections or sepsis/urosepsis Multiple retained failed transplants prior to a repeat transplantThe presence of hematologic or biochemical markers of the chronic inflammatory state Erythropoietin resistance anemia Elevated ferritin level Elevated C reactive protein Elevated erythrocyte sedimentation rate Low prealbumin/albumin Graft loss due to BK nephropathy and high level BK viremia (see text)