The management of the failed renal allograft: an enigma with potential consequences

The number of patients returning to dialysis after their renal allograft fails is increasing in absolute numbers year after year. The management of the failed allograft that is not immediately symptomatic remains controversial. Surgical mortality and morbidity, a rising number of circulating antibodies, reduced erythropoietin, and diuresis are among the arguments to support simply observing the failed allograft. Chronic inflammation, potential for malignancy, infection, and the need for low-dose immunosuppression are concerns that might goad one into performing a preemptive nephrectomy. Based on the current literature and our own clinical experience, we believe allograft nephrectomies should not be routinely performed. They should be reserved for those patients who develop particular symptoms attributable to the allograft or those who require space for retransplantation. Future studies that address this issue in addition to testing various immunosuppression attrition rates may be able to discern a protocol that minimizes drug exposure while leading to reduced nephrectomy rates after returning to dialysis.