Indications, risks and impact of failed allograft nephrectomy

In this review, we describe the indications, surgical aspects, benefits and risks of nephrectomy after graft failure. There is a great variation in the number of allograft nephrectomies performed among different centers. Nephrectomy of a failed allograft is associated with significant morbidity and mortality with a complication rate of 20-30% and mortality rates between 0% and 11%. A systematic review through Medline (Pubmed) and Embase identified thirteen retrospective studies that compared patients with and patients without allograft nephrectomy prior to retransplantation. Allograft nephrectomy associates with an increased risk of HLA antibody development. With two recent studies that used the more sensitive HLA antibody detection methods disproving the hypothesis of intragraft adsorption of HLA antibodies, the mechanism leading to the increased HLA antibody levels is not clear, but the role of immunosuppression withdrawal is becoming clear and needs further investigation. In nine of the thirteen studies that evaluated the impact of allograft nephrectomy on outcome in retransplantation, retransplant graft survival was not significantly different among patients with and patients without allograft nephrectomy. Only three studies showed significantly worse retransplant graft survival if prior allograft nephrectomy was performed. Most studies did not observe a significant difference in patient survival after retransplantation with versus without prior allograft nephrectomy. All studies were affected by the retrospective design, indication bias, and selection bias. On the basis of the available literature on this topic, we did not identify a clear advantage or disadvantage of allograft nephrectomy, in terms of outcome after repeat transplantation. Nevertheless, the significantly increased risk of HLA antibody sensitization, especially in patients at high immunological risk like high donor-recipientHLA epitope mismatch load and HLA-DQB1 mismatches, argues against routine allograft nephrectomy and immunosuppression withdrawal in asymptomatic patients who are eligible for repeat transplantation.