Along the last era, kidney allograft survival has been greatly improved particularly after the advent of the new Im/m regimens.
FAILED
TRANSPLANT
Abbreviations:
o DX: dialysis.
o
ESA: erythropoiesis-stimulating agent.
o
ESKD: end-stage kidney disease.
o
Im/m: immunosuppression/ immunosuppressives.
o
KTx: kidney transplant.
o
MR: mortality rate.
o
RRT: renal replacement therapy.
o
Sms: symptoms
o
TR: transplant recipients.
o Tx: Transplant.
Along the last era,
kidney allograft survival has been greatly improved particularly after the
advent of the new Im/m regimens. However, this improvement was associated with a considerable
number of kidney TR who are
currently requiring the permanent resumption of RRT owing to kidney allograft failure.
Consequently, an important question has been arising in the management
of the TR
with a lost kidney allograft, when & how to withdraw the maintenance
Im/m therapy in a safe mode.
Generally, the crucial target is to hold the Im/m medications without inducing rejection process, leading to any
adverse sequela due to drug withdrawal, or aggravating allosensitization cascade.
Furthermore, the effect of sensitization process should be assessed for ptns considered
for next transplant. Continuing of Im/m might be mandated for ptns feeling too frail to accommodate allograft
nephrectomy, as it considered a major operation. For a lost allograft a
suggested approach is as follows:
1) Ptns
with kidney allograft failure seen <1 y. post-Tx
(early graft loss), preemptive
nephrectomy + rapid Im/m holding at the time of nephrectomy is suggested.
2) Ptns
with kidney allograft failure seen >1 y. post-Tx
(late graft loss), gradual holding of
Im/m, rather than nephrectomy & immediate holding of Im/m is suggested. A particular approach varies according to future ptn
plans of receiving another KTx within one y., in addition to ptn's residual kidney function. All ptns should be strictly
monitored for Sms of rejection and also for impending adrenal failure.
Withdrawing Im/m medications may be complicated by many sequelae including:
o
Secondary adrenal
failure,
o
Lost residual
kidney function,
o
ESAs resistance >
worsened anemia.
o
Precipitated rejection with the need
for graft nephrectomy,
o
Triggering adverse immunologic sequelae among TR pending another
Tx,
Surgical removing of renal allograft (Tx
nephrectomy) is commonly resorted to in ptns returning to DX following the loss of a kidney transplant.
The most commonly observed indication for Tx
nephrectomy is the onset of Sms and/or sequelae related to the evolution of the rejection
process after holding Im/m and the history of early graft failure (with or with no Sms and/or associated
complications).
Ptns may need DX after their Tx
kidney lost function that may continue for years after Tx. Ptns returning to chronic DX after a Tx kidney failure have a high MR as compared to ptns with a functioning graft and
also if compared to ptns maintained on chronic DX and not receiving a KTx.
Indication for the start of maintenance DX among TR with failed graft are the same as that of non-Tx ptns with ESKD.
For most ptns with kidney graft failure seen
<1 y post-Tx, a short period of DX (1-4 weeks) prior to Tx
rather than the attempt of preemptive Tx.
For most TR
with kidney graft failure seen >1 y. after Tx,
preemptive Tx, rather than a period
of DX before
Tx is suggested.
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