Timing of Return to Dialysis in Patients with Failing Kidney Transplants

Abstract

In the last decade, the number of patients starting dialysis after a failed kidney transplant has increased substantially. These patients appear to be different from their transplant‐naïve counterparts, and so may be the timing of dialysis therapy initiation. An increasing number of studies suggest that in transplant‐naïve patients, later dialysis initiation is associated with better outcomes. Very few data are available on timing of dialysis reinitiation in failed transplant recipients, and they suggest that an earlier return to dialysis therapy tended to be associated with worse survival, especially among healthier and younger patients and women. Failed transplant patients may also have unique issues such as continuation of immunosuppression versus withdrawal or the need for remnant allograft nephrectomy with regard to dialysis reinitiation. These patients may have a different predialysis preparation work‐up, worse blood pressure control, higher or lower serum phosphorus levels, lower serum bicarbonate concentration, and worse anemia management. The choice of dialysis modality may also represent an important question for these patients, even though there appears to be no difference in mortality between patients starting peritoneal versus hemodialysis. Finally, failed transplant patients returning to dialysis appear to have a higher mortality rate compared with transplant‐naïve incident dialysis patients, especially in the first several months of dialysis therapy. In this review, we will summarize the available data related to the timing of dialysis initiation and outcomes in failed kidney transplant patients after returning to dialysis.

Mortality after Renal Allograft Failure and Return to Dialysis

“…Ojo et al [15] reported 5-year patient survival after primary renal allograft failure was 36, 49, and 65% for type I diabetes mellitus (DM), type II DM, and non-diabetic ESRD patients, respectively ( p < 0.001; DM vs. non-diabetics). Close monitoring and management of comorbid disease is essential for risk reduction in these patients [7,9]. The most common causes of death in our study included cardiac and infectious diseases, which is consistent with the current literature [16,17,18,19].…”

“…Allograft failure is often due to rejection, drug toxicity, and chronic allograft nephropathy [8]. Graft failure and return to dialysis (RTD) confers a greater mortality risk than in transplant-naive patients starting dialysis [9]. …”

Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease

“…In recent years, in the USA 30% and 15% of patients transition to dialysis with an eGFR of 10 to <15 and ≥15 mL/min/1.73 m 2 , respectively [9]. However, very few if any patients ever transition to RRT with an eGFR >25 mL/min/1.73 m 2 ( Figure 2) [11]. Although several studies have questioned the wisdom of premature dialysis initiation [12], it remains unknown as to when the best timing for ESRD transition should occur for individuals, i.e.…”

“…across different age groups or comorbid conditions or race/ethnicities, in order to achieve the best ESRD survival and other outcomes. There are a number of key unanswered questions related to the transition of care in CKD [11,13]. For instance, there is an urgent need to examine whether the transition to RRT and the type and modality of the transition should be selected based on pre-dialysis patient data.…”

Mensuração da adesão aos medicamentos imunossupressores em receptores de transplante renal

“…(6,11) The risk for death or recipient's return to dialysis after graft failure is higher compared with those on the waiting list for dialysis. (12) Studies have evaluated different strategies to identify nonadherence, including pill counts, self-report, collateral effect register, laboratory analyses of immunosuppressive drug levels, and electronic monitoring. This last is considered the gold standard for identifying adherence to immunosuppressive therapy but is not always viable because of its high cost.…”