Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ FACTORS TO BE CONSIDERED ++ What are the identifiable causes of allograft failure? Is the patient going to outlive the failing allograft? Is the patient retransplantable? Is there a reason to interrupt immunosuppression? How to modify immunosuppression How to preserve remaining allograft function Management of end-stage renal disease (ESRD) in prior kidney recipient Preparing for a retransplant Retransplantation and follow-up care +++ CAUSES OF FAILING RENAL ALLOGRAFT ++ Who are the innocent bystanders? Who is at fault here? Is it the kidney? Is it the recipient? Is it the medical team? Is it just an unavoidable outcome? +++ FAILING ALLOGRAFT: IMMUNOLOGICAL CONSIDERATIONS ++ Chronic rejection Antibody-mediated rejection High immunological risk transplant Human leukocyte antigen (HLA) mismatch Suboptimal immunosuppression Suboptimal adherence to treatment Sensitized recipient +++ RECIPIENT OF A SUBOPTIMALLY FUNCTIONING KIDNEY ++ Injury during organ recovery Prolonged ischemia time Loss of renal parenchyma due to small accessory vessels Preexisting diseases in donor kidney Significant donor–recipient age and size mismatch Mechanical-vascular/urological issues Suboptimal surgical techniques Genetically destined to fail faster (ApoL1) +++ FAILING ALLOGRAFT: INFECTIONS ++ Recurrent urinary infections, BK virus (BKV), adenovirus Recurrence of kidney disease: focal segmental glomerulosclerosis (FSGS), IgA, lupus, hemolytic uremic syndrome (HUS), oxalosis Intentional reduction in immunosuppression BKV, cytomegalovirus (CMV) Posttransplant lymphoproliferative disorder (PTLD) Malignancy Major/recurrent/opportunistic infections +++ OUTCOME FOLLOWING FAILED RENAL ALLOGRAFT ++ Successful transplantation tries to achieve improved longevity and quality of life Causes of mortality following failed renal allograft: Cardiac (36%) Infectious (17%) +++ ALLOGRAFT NEPHRECTOMY, CESSATION OF IMMUNOSUPPRESSION, AND IMMEDIATE DIALYSIS INITIATION ++ Primary nonfunction Early allograft failure Vascular event: arterial or venous thrombosis Hyper-acute rejection Early refractory acute rejection Prevents graft rupture and hemorrhage +++ ALLOGRAFT PRESERVATION, CONTINUATION OF IMMUNOSUPPRESSION, AND DELAYED DIALYSIS INITIATION ++ Allograft loss more than 1–2 years after transplant: Preserve residual allograft function: survival advantage1 Prevents graft intolerance syndrome/inflammatory state Minimizes allosensitization +++ ALLOGRAFT PRESERVATION: CONTINUATION OF IMMUNOSUPPRESSION ++ Prevents reactivation of autoimmune diseases: irritable bowel disease (IBD), systemic lupus erythematosus (SLE), vasculitides Cardiovascular, infectious, metabolic complications Increased risk of cancers: skin, non-Hodgkin lymphoma (NHL), and Kaposi +++ ALLOGRAFT FUNCTION PRESERVATION: STRATEGIES ++ Optimization of immunosuppression Calcineurin inhibitor (CNI) minimization Costimulatory blockade Managing chronic antibody-mediated rejection (AMR) Ensuring vascular adequacy Managing cardiovascular (CV) and chronic kidney disease (CKD) risk factors: diabetes mellitus (DM), hypertension (HTN), hypersensitivity lung disease (HLD) Optimizing bladder function Nutrition, sleep, exercise, body weight Avoiding nephrotoxic agents: nonsteroidal anti-inflammatory drugs (NSAIDs), tobacco, cocaine, contrast media +++ ALLOGRAFT NEPHRECTOMY ++ Early allograft loss (<12 months): twice as likely to undergo allograft nephrectomy in United States Renal Data System (USRDS) cohort2 Fourfold likely to have nephrectomy in ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.