The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients

Lubetzky, Michelle; Tantisattamo, Ekamol; Molnar, Miklos Z.; Lentine, Krista L.; Basu, Arpita; Parsons, Ronald F.; Woodside, Kenneth J.; Pavlakis, Martha; Blosser, Christopher D.; Singh, Neeraj; Concepcion, Beatrice P.; Adey, Deborah; Gupta, Gaurav; Faravardeh, Arman; Kraus, Edward S.; Ong, Song; Riella, Leonardo V.; Friedewald, John; Wiseman, A.; Aala, Amtul; Dadhania, Darshana; Alhamad, Tarek

doi:10.1111/ajt.16717

Cited by 34 publications

(39 citation statements)

References 54 publications

(135 reference statements)

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“…A group of experts proposed in 2021 that the failing allograft definition should include patients with stable but low allograft function; irreversible and progressive decline in kidney function with anticipated graft loss in less than 1 year; and a return to renal replacement therapy, maintenance dialysis, new wait-listing or repeat transplantation [ 19 ]. Figure 1 summarizes the management of the patient with a failing renal graft.…”

Section: Management Of the Failing Allograftmentioning

confidence: 99%

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Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review

Leal

Pardinhas

Martinho

et al. 2022

JCM

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Patients with a failed kidney allograft have steadily increase in recent years and returning to dialysis after graft loss is one of the most difficult transitions for chronic kidney disease patients and their assistant physicians. The management of these patients is complex and encompasses the treatment of chronic kidney disease complications, dialysis restart and access planning, immunosuppression withdrawal, graft nephrectomy, and evaluation for a potential retransplant. In recent years, several groups have focused on the management of the patient with a failing renal graft and expert recommendations are arising. A review of Pubmed, ScienceDirect and the Cochrane Library was performed focusing on the specific care of these patients, from the management of low clearance complications to concerns with a subsequent kidney transplant. Conclusion: There is a growing interest in the failing renal graft and new approaches to improve these patients’ outcomes are being defined including specific multidisciplinary programs, individualized immunosuppression withdrawal schemes, and strategies to prevent HLA sensitization and increase retransplant rates.

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Section: Management Of the Failing Allograftmentioning

confidence: 99%

“…Additionally, a recent trial that included 45 patients with graft loss that maintained tacrolimus for 24 months, showed that higher tacrolimus levels (≥3 mg/dL) were protective against allosensitization [ 61 ]. Lubetzky et al determined tacrolimus as 3–5 ng/mL [ 19 ].…”

Section: Management Of the Failing Allograftmentioning

confidence: 99%

Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review

Leal

Pardinhas

Martinho

et al. 2022

JCM

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“…It is demonstrated that KT provides superior life expectancy [61][62][63] and QoL [64][65][66] than dialysis. Nonetheless, returning to dialysis after a failed transplant entails a greater risk of death than starting RRT for the first time [11,40,43,67,68]. Therefore, preserving graft function as much as possible is vital for long-term patient survival.…”

Section: Post-transplant Recipient and Allograft Survivalsmentioning

confidence: 99%

“…Even though several studies have demonstrated that PD does not exert any negative impact on transplant-related outcomes [31][32][33], some clinicians remain reluctant to propose this dialysis option to patients on the transplant waiting list (TWL) [34,35]. Such an attitude is certainly questionable since ICHD, home HD (HHD), and PD should not be regarded as competitive modalities, rather as complementary strategies before [36][37][38][39] and after transplant [40][41][42][43]. Indeed, RRT must be tailored to the specific needs and characteristics of the patient, taking into account the time-dependent variability of these parameters and local facilities [44].…”

Section: Introductionmentioning

confidence: 99%

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

et al. 2022

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Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient’s needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

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“…Otherwise, IS must be considered on an individual basis [ 31 ]. The Kidney Recipient with Allograft Failure Transition of Care (KRAFT) group consider that patients with a prospect of a subsequent KT, should maintain IS in the first year post graft failure with a reduction of 50% of antimetabolite at dialysis start and suspension at 3 months, and maintaining CNI (with progressive dose reduction) with or without low dose steroids for one-year after graft loss [ 62 ]. Must authors are consensual that frequent HLA monitoring should be done, especially when IS is altered or acute events occur, such as infections or signs of GIS [ 15 , 31 ].…”

Section: Strategies To Increase Retransplantation Access ( ...mentioning

confidence: 99%

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss

Leal

Pardinhas

Martinho

et al. 2022

JCM

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An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.

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The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients

Cited by 34 publications

References 54 publications

Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review

Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss

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