Practice patterns and influence of allograft nephrectomy in pediatric kidney re‐transplantation: A pediatric nephrology research consortium study

Abstract

Introduction There are no guidelines regarding management of failed pediatric renal transplants. Materials & Methods We performed a first of its kind multicenter study assessing prevalence of transplant nephrectomy, patient characteristics, and outcomes in pediatric renal transplant recipients with graft failure from January 1, 2006, to December 31, 2016. Results Fourteen centers contributed data on 186 pediatric recipients with failed transplants. The 76 recipients that underwent transplant nephrectomy were not significantly different from the 110 without nephrectomy in donor or recipient demographics. Fifty‐three percent of graft nephrectomies were within a year of transplant. Graft tenderness prompted transplant nephrectomy in 91% (P < .001). Patients that underwent nephrectomy were more likely to have a prior diagnosis of rejection within 3 months (43% vs 29%; P = .04). Nephrectomy of allografts did not affect time to re‐listing, donor source at re‐transplant but significantly decreased time to (P = .009) and incidence (P = .0002) of complete cessation of immunosuppression post‐graft failure. Following transplant nephrectomy, recipients were significantly more likely to have rejection after re‐transplant (18% vs 7%; P = .03) and multiple rejections in first year after re‐transplant (7% vs 1%; P = .03). Conclusions Practices pertaining to failed renal allografts are inconsistent—40% of failed pediatric renal allografts underwent nephrectomy. Graft tenderness frequently prompted transplant nephrectomy. There is no apparent benefit to graft nephrectomy related to sensitization; but timing / frequency of immunosuppression withdrawal is significantly different with slightly increased risk for rejection following re‐transplant.

Management of the sensitized pediatric renal transplant candidate

“…There is no apparent benefit to graft nephrectomy related to sensitization, but timing and frequency of immunosuppression withdrawal is significantly different with slightly increased risk for rejection following re-transplant. 73 In addition to these measures, individuals with a failing allograft need to be relisted as soon as their GFR will allow, to minimize time on the wait list and therefore their time on dialysis, if a preemptive transplant is not possible.…”

“…Following transplant nephrectomy, recipients were significantly more likely to have rejection after re‐transplant (18% vs. 7%; p = .03) and multiple rejections in the first year after re‐transplant (7% vs. 1%; p = .03). There is no apparent benefit to graft nephrectomy related to sensitization, but timing and frequency of immunosuppression withdrawal is significantly different with slightly increased risk for rejection following re‐transplant 73 …”