CHAPTER 71: Management of the Kidney Recipient with a Failing Allograft

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 ...