Allograft nephrectomy: Indications and surgical techniques. Association Française d'Urologie and Société Francophone...

After kidney graft failure, the question of maintaining or removing the graft arises. The indications and surgical techniques of transplant nephrectomy as well as the peri-procedure immunosuppressor management are poorly codified and are not the subject of any specific guidelines. The aim of this work was to provide clinical guidelines focused on four clinical questions: (i) indications and timing of transplant nephrectomy; (ii) immunological impact and immunosuppressant management before, during and after transplant nephrectomy; (iii) surgical techniques; and (iv) alternatives to transplant nephrectomy/conservative treatments (e.g. embolization).

These guidelines were based on a systematic review of studies published between January 2000 and March 2024 performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. In total, 2144 publications were screened and 84 met the inclusion criteria. These guidelines were elaborated by a multidisciplinary task force and reviewed by independent experts.

Routine transplant nephrectomy to limit anti-HLA immunization is not recommended (Grade C). The indications for early and late transplant nephrectomy have been clarified as well as the importance of patient information. The data do not provide conclusive evidence in favor of the abrupt discontinuation or gradual withdrawal of immunosuppressors after transplant nephrectomy (expert agreement, EA). Decision-making about immunosuppressor tapering or low-dose immunosuppressor maintenance after transplant nephrectomy should take into account the perspective of retransplantation and the development of anti-HLA antibodies (EA). Transplant nephrectomy should be carried out using the intracapsular approach in patients with corticosteroid-resistant graft intolerance syndrome (Grade C). The extracapsular approach should be chosen when transplant nephrectomy is performed early or for kidney graft tumors and the intracapsular approach for late procedures (EA). Embolization may be proposed as an alternative to graft nephrectomy in patients with graft intolerance syndrome and frailty or who refuse surgery (EA).

These guidelines describe the indications, surgical techniques, immunological context and alternatives to transplant nephrectomy in order to improve the management of patients with kidney graft failure. Many questions remain about the immunological impact of transplant nephrectomy.