Background
The number of patients with a failed kidney allograft who return to dialysis is increasing. The mortality in these patients clearly increases with the resumption of dialysis compared to patients with a functioning transplant. The main causes of death are cardiovascular and infectious complications.
Objective
The challenges in the clinical management of patients with kidney graft failure are the timing of return to dialysis, the management of immunosuppression and the indications for transplant nephrectomy. This review article provides a critical review of the current evidence regarding these questions.
Material and methods
The currently available literature was reviewed based on a search in the PubMed database.
Results
The decision to reinitiate dialysis treatment should primarily be based on the clinical symptoms of renal insufficiency and comorbidities. There is no general preference for any specific dialysis modality. The timing and speed of immunosuppression weaning depend on the residual function of the allograft, time of graft failure after transplantation, risk for infectious complications and possible plans for retransplantation. A transplant nephrectomy is indicated when acute symptoms ,such as pain and swelling of the graft (e. g. hyperacute or treatment-refractory rejection and disturbed blood perfusion) or a chronic inflammatory syndrome are present. Transplant nephrectomy is generally not indicated for asymptomatic grafts due to the high rate of surgical complications and lack of proven benefit.
Conclusion
Recommendations are given for the management of patients with a failed transplanted kidney regarding timing of dialysis initiation, immunosuppression weaning and transplant nephrectomy; however, decisions need to be adjusted to the unique needs of each individual patient.