When and why to perform allograft nephrectomy? A systematic review from the AFU-SFT collaboration

Allograft nephrectomy (AN) after graft failure remains controversial, balancing symptom control and facilitation of immunosuppression withdrawal against operative risk and uncertain immunological consequences. A systematic review of literature published from January 2000 to March 2024 in accordance with PRISMA guidelines was performed. We included studies addressing indications, timing, complications and outcomes related to subsequent transplantation. Thirty-nine studies were included. Reported prevalence varied widely but was <10% in most contemporary cohorts and declined after the cyclosporine era. Early AN was mainly performed for primary non-function, severe acute rejection, and surgical or vascular complications. Late transplantectomy was more often related to graft intolerance syndrome, refractory hypertension, or chronic infection. Overall morbidity was about 18% and mortality 4%, with higher risk in emergency settings. AN was not associated with improved recipient or graft survival after retransplantation, although it may increase sensitization and early graft-related events. In children, AN appeared more frequent than in adults, but evidence remained limited. Overall, AN appears to be an indication-driven rather than routine intervention, requiring individualized risk-benefit assessment within a retransplant strategy.