Cumulative Incidence, Indications, Morbidity And Mortality of Transplant Nephrectomy And The Most Appropriate Time For Graft Removal: Only Nonfunctioning Transplants That Cause Intractable Complications Should Be Excised

Abstract

Most transplant nephrectomies were performed within 2 years of the transplant date and almost half were done within year 1 after the return to dialysis. The advent of cyclosporine significantly decreased the transplant nephrectomy rate at the expense of fewer graft failures but not at the expense of a lower amount of graft related symptoms after patients returned to dialysis. Bleeding was the leading cause of morbidity and infection was the main cause of mortality. Considering the high morbidity and mortality of transplant nephrectomy, and the potential benefits of leaving nonfunctioning grafts in situ our current policy is to remove the graft only in cases of failed transplants that cause intractable complications.

Nephrectomy After Transplant Failure: Current Practice and Outcomes

“…The role of transplant nephrectomy in the management of transplant failure patients has only been examined in small single center studies (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15). Some investigators have advocated against the removal of the asymptomatic failed allograft due to the morbidity and mortality associated with transplant nephrectomy (9,12).…”

Robotic Trans-Abdominal Transplant Nephrectomy for a Failed Renal Allograft

“…In this case, early control of vascular inflow resulted in minimal blood loss (less than 25 cm 3 ) and there was no need for a peri-operative blood transfusion. Finally, one of the significant complications reported with open TN is post-operative superficial and deep wound infections (1)(2)(3)(4)(5). While definitive conclusions cannot be drawn from one case, we anticipate that due to the reduced size of the robotic TN incisions and the reduction in blood loss that the overall incidence of significant superficial and deep wound infections will be decreased in robotic TN patients.…”

“…The presence of postsurgical scarring and dense inflammation make dissection and removal of the failed allograft technically demanding. In recent series of TN significant morbidity was reported in 10-40% of patients and was mostly attributed to hemorrhage or infection (1)(2)(3)(4)(5). However, significant injuries to surrounding structures such as the bladder, colon and iliac vessels have been reported as well (1,3,5).…”

“…However, significant injuries to surrounding structures such as the bladder, colon and iliac vessels have been reported as well (1,3,5). The overall mortality rate associated with TN ranged from 3% to 9% and was mostly attributed to septic complications following surgery (1)(2)(3)(4)(5). In summary, TN is an invasive procedure associated with significant potential morbidity and mortality risk as well as considerable patient discomfort.…”

Sequestration and Suppression of Anti-HLA Antibodies by a Failed Kidney Allograft

“…Transplant nephrectomy may also limit long-term cardiovascular risk (1). Despite these potential benefits, transplant nephrectomy can be complicated by morbidities surrounding surgery, and several retrospective reports suggest that nephrectomy is associated with an increase in circulating anti-HLA antibodies (1)(2)(3)(4)(5)(6). The enduring implications of the latter are significant because anti-HLA antibodies confer both an increase wait time for retransplantation and elevated risk for subsequent graft failure (7,8).…”