Managing patients with a failed kidney transplant: how can we do better?

Patients with a failed kidney transplant represent a unique chronic kidney disease (CKD) population that is increasing in number, and that is at high risk of morbidity and mortality because of a prolonged history of CKD that may be sub-optimally managed, and exposure to immunosuppressant medications that are often continued after transplant failure.

There is no consensus on the optimal use of immunosuppressant medications after transplant failure. Recent observational studies have demonstrated that surgical removal of the failed allograft and discontinuation of immunosuppressant medications may be associated with a decreased long-term risk of mortality. However, the indications for elective transplant nephrectomy remain poorly defined. Removal of the failed allograft may limit opportunities for repeat transplantation by increasing cytotoxic antibody levels, and may be associated with an increased risk of repeat transplant failure.

In the absence of controlled studies, judicious use of immunosuppressant medications based on the patient's suitability for repeat transplantation, anticipated time to repeat transplantation, risk of sensitization, and drug tolerance, together with a cohesive plan for CKD management and appropriate preparation for dialysis, may improve outcomes in this unique patient population.