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 click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. 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 Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth