Management considerations in the failing renal allograft

Patients with a failed or failing renal transplant are increasing in number. Graft failure resulting in dialysis re-initiation is not uncommon, yet there are limited data to guide management of these patients. Physician practices vary regarding timing of dialysis initiation and the timing and extent of immunosuppression withdrawal. The risks of immunosuppression withdrawal need to be carefully balanced against the benefits of continuing low-dose therapy. The latter helps minimize the risk of sensitisation and has been proposed to possibly slow the loss of residual renal function; however, the use of common immunosuppressive agents may contribute to cardiovascular disease, malignancy, and infection, the major causes of death following the loss of a renal transplant. The evolving area of personalised transplant immunosuppression may offer future tools for monitoring and managing patients during and after transplant failure. This article aims to discuss some of the important issues that arise when managing these patients.