Third kidney transplantation: a permanent medical-surgical challenge

The aim of this study was to analyze the 30 third transplantations performed at our center since 1976. They were all from cadaveric donors. Recipient mean age was 40 years (range, 21-57 years). Twenty-one patients (70%) had hepatitis C virus infection and 16 (53%) were hypersensitized (panel-reactive antibodies [PRA] >50%), with a mean time on dialysis since second graft loss of 65 months (range, 1-250 months). The imaging tests showed iliac calcifications in 14 patients (47%). The graft was preferably placed in the iliac fossa (27/30). Twenty-five patients (83%) had prior graft nephrectomy and transplantectomy was performed at the same surgery in 2 cases. Immunosuppressive protocol was quadruple therapy in 23 patients (77%). At a mean follow-up of 43 months, 24 grafts were functioning. Mean serum creatinine was 1.5 mg/dL and Modification of Diet in Renal Disease (MDRD) clearance was 64.5 mL/min. Six grafts were lost: 3 due to acute rejection, 2 due to chronic allograft nephropathy, and 1 due to venous thrombosis. Four patients died: 2 due to infectious complications, 1 due to hepatic encephalopathy, and 1 to an accident with a functioning graft. The acute rejection rate was 30% and 4 patients had an acute humoral rejection episode. The main surgical complication was lymphocele in 7 cases (23%). Estimated survival at 5 years was 76% for grafts and 86% for patients. Graft survival worsened among patients with PRA > 80% and among those who had lost the previous grafts in the first month posttransplantation (P < .05). In conclusion, the outcomes of the third kidney transplantations encourage us to continue with this procedure. However, worse graft survival should be expected among hyperimmunized patients and among those who had lost previous grafts early in their course.