Pre-Emptive Retransplantation in Patients With Chronic Kidney Graft Failure

doi:10.1016/j.transproceed.2015.09.003

Transplantation Proceedings

Volume 47, Issue 8, October 2015, Pages 2351-2353

https://doi.org/10.1016/j.transproceed.2015.09.003 Get rights and content

Abstract

Introduction

The aim of this study was to compare the group of patients receiving a new kidney transplant before starting dialysis again (pre-reTR) with a group of patients receiving a new kidney transplant after restarting dialysis (reTR).

Methods

This retrospective cohort included all the kidney retransplantations (second transplantations) between 2000 and 2012 performed at our center and their follow-up until July 2014. We analysed graft and patient survival, rejection rates, and immunologic parameters of these patients.

Results

We studied 18 patients who had pre-reTR and 83 who had reTR. In the pre-reTR group no patient had panel-reactive assay (PRA) >10% at any time. In the reTR group 26.5% had PRA >10% at the time of transplantation (P = .014) and 54.2% had a historical highest PRA >10% (P < .001). The rejection rate was 11.1% in the pre-reTR group and 27.7% in the reTR group during the first year post-retransplantation (P = .227). Patient survival rate was 100% in the pre-reTR group at 5 years of follow-up, whereas in the reTR group at 1 year it was 95.2% and 85.9% at 5 years after retransplantation. Allograft survival at 1 and 5 years was 88% and 89%, respectively, in the pre-reTR group. On the other hand, in the reTR group it was 89% after the first year and 65% at 5 years post-retransplantation.

Conclusion

Pre-emptive renal retransplantation is a feasible option that should be assessed in patients with kidney graft failure and may help to minimize the morbidity associated with dialysis reinitiation.

Section snippets

Methods

We performed a retrospective observational cohort study. We identified all retransplantations performed between the years 2000 and 2012 at the Hospital Clinic in Barcelona. These patients were monitored until July 2014. Data was collected from the electronic hospital database.

Two groups were created for analysis: pre-reTR and reTR. Transplanctectomy rates before retransplantation were also taken into account as an influencing factor. We studied the following: patient- and death-censored graft

Results

A total of 101 patients were analysed: 18 received pre-reTR, and 83 nonpre-emptive reTR. The mean ages in the pre-reTR and re-TR groups were 45 and 55 years old, respectively. In our series, living donation accounts for 88.9% in the pre-reTR receptors, whereas the reTR had a 19.3%. Table 1 resumes the variables of renal function. Noticeably there were no differences between both groups.

Discussion

In the last years, it has been proven that pre-emptive first kidney transplantations yield better results than those performed after a period of dialysis [4], [5], [6], [7], [8]. However, it is not yet clear what possible benefits could derive from pre-emptive retransplantation.

At this point, the benefits in pre-emptive retransplantation can be theorized. First of all, the pre-emptive retransplantation could lessen the immunologic sensitization stimuli. The withdrawal or reduction of the

Conclusion

Pre-emptive renal retransplantation is a feasible option that should be assessed in patients with kidney graft failure and may help to minimize the morbidity associated with dialysis reinitiation. However, in the light of organ scarcity this strategy is probably restricted to patients with a living donor.

In our series, almost 89% of pre-emptive recipients were patients who received a live donor transplant versus 19% in the reTR group after initiating dialysis. Therefore, at least these 19% of

References (10)

F. Cosio et al.
Patient survival after kidney transplantation. I. The impact of dialysis pre-transplant
Kidney Int
(1998)
H. Kaul et al.
Initiation of hemodialysis treatment leads to improvement of T-cell activation in patients with end-stage renal disease
Am J Kidney Dis
(2000)
R.A. Wolfe et al.
Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant
N Engl J Med
(2007)
P. Messa et al.
Coming back to dialysis after kidney transplant failure
Nephrol Dial Transplant
(2008)
P.S. Rao et al.
Evaluating the survival benefit of kidney retransplantation
Transplantation
(2006)

There are more references available in the full text version of this article.

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Management of an aneurysmal arteriovenous fistula in kidney transplant recipients
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Aneurysms remain the most common complication of an arteriovenous fistula created for dialysis access. The management of an aneurysmal arteriovenous fistula (AAVF) in kidney transplant recipients remains contentious with a lack of clear clinical guidelines. Recipients of a functioning graft do not require the fistula for dialysis access, however risk of graft failure and needing the access at a future date must be considered. In this review we outline the current evidence in the assessment and management of a transplant recipient with an AAVF. We will describe our recommended five-step approach to assessing an AAVF in transplant patients; 1.) Define AAVF 2.) Risk assess AAVF 3.) Assess transplant graft function and future graft failure risk 4.) Consider future renal replacement therapy options 5.) Vascular mapping to assess future vascular access options. Then we will describe the current therapeutic options and when they would most appropriately be employed.
What are the benefits of preemptive versus non-preemptive kidney transplantation? A systematic review and meta-analysis
2023, Transplantation Reviews
Opting for a preemptive kidney transplant (PKT) can help avoid costs and morbidity associated with dialysis. However, while multiple studies have shown clinical benefits of PKT, other studies have not demonstrated this, leading to controversy in the literature regarding the exact benefits of PKT. Therefore, this study aimed to determine the clinical outcomes of PKT versus non-preemptive kidney transplantation (nPKT) in adult patients. Multiple databases were searched up to May 4, 2022. Independent reviewers selected studies for inclusion and extracted relevant data. Risk of bias was assessed using the Downs and Black checklist. Eighty-seven studies including 859,715 adult kidney transplant patients were included the review. The risk of patient death (relative risk [95% confidence interval] 0.74 [0.60–0.91]) was significantly lower in PKT versus nPKT patients for living donor (LD) transplants, whereas the risk of overall graft loss was significantly lower in PKT compared to nPKT patients for both LD (0.72 [0.62–0.83]) as well as deceased donor (DD) transplants (0.80 [0.69–0.92]). The evidence suggests that LD PKT patients have a lower risk of patient death and graft loss compared to nPKT patients, and DD PKT patients have a lower risk of graft loss than nPKT patients.
Pre-emptive second renal transplant from deceased donor: A new trend
2022, Nefrologia
Review: Management of patients with kidney allograft failure
2018, Transplantation Reviews
Citation Excerpt :
In addition, there was a trend towards fewer acute rejections, and improved graft- and patient survival. However, patients with a pre-emptive retransplantation were younger and received a living donor kidney more often than patients who were retransplanted after a period on dialysis [91]. In contrast, a retrospective analysis of USRDS and UNOS data showed that pre-emptive retransplantation was associated to an increased risk of graft loss (HR 1.36, 95% confidence interval 1.21–1.54 [92].
Late allograft loss in kidney transplant recipients remains a common problem and is associated with high mortality and morbidity. The management of patients with a failed kidney allograft includes a few major dilemmas: when to start dialysis, what is the optimal management regarding immunosuppression, and should an allograft nephrectomy be performed. In suitable candidates for a repeated transplantation there are additional matters to take in consideration. In this review we will discuss these dilemmas by providing an overview of current evidence and gaps in our knowledge. As many of these issues are incompletely resolved, we conclude that more studies are needed to improve the management of patients with a failed kidney allograft.
Influence of Pretransplant Dialysis Vintage on Repeated Kidney Transplantation Outcomes
2018, Transplantation Proceedings
Citation Excerpt :
Several settings of this study's design differed from other authors' because we attempted to detect the “threshold” of dialysis at which repeated transplantation outcomes became significantly worse. Most authors [22,23,33] divided patients in just 2 groups—those who had undergone repeated transplantation without returning to dialysis and those that received dialysis treatment. Here, we divided patients into 4 groups according to the duration of pretransplant dialysis because this permitted better detection of the “dose-dependent” effect of dialysis.
Dialysis has a dose-dependent effect on first kidney transplantation outcomes, and a shorter waiting time on dialysis is associated with superior graft function. There are not enough data to support this statement in the case of a repeated transplantation. As such, we aimed to evaluate the influence of the dialysis vintage before the last transplantation on graft function as well as patient and graft survival in repeated transplantation situations. Patients who underwent repeated kidney transplantations were included in the retrospective study. Specifically, 79 patients were included who were divided into 4 groups according to the dialysis vintage before the last transplantation. We assessed graft function and patient and graft survival rates after 1- and 3-year follow-up. One-year graft function was worse for patients with a dialysis vintage of more than 31 months (P = .005), but there was no difference after 3 years. One- and 3-year graft survival was better for patients with a dialysis vintage of less than 12 months (P = .017). We concluded that a longer waiting time on dialysis was associated with worse graft function and diminished long-term graft survival after repeated kidney transplantation.
Temporal Trend and Time-Varying Effect of Preemptive Second Kidney Transplantation on Graft Survival: A 30-Year Single-Center Cohort Study
2016, Transplantation Proceedings
Citation Excerpt :
However, residual confounding may persist. In addition, although immunosuppressive regimens have indeed changed during the 30-year study period, this very long follow-up nonetheless allowed us to identify a time-varying effect of preemptive SKT that was not observed in earlier studies with shorter follow-up durations [11–13]. The definition of delayed graft function remains controversial [22].
There are discrepancies regarding the impact of preemptive 2nd kidney transplantation (PSKT) on graft survival. The present study aimed to determine whether the association between PSKT and outcome varies over time and whether this association is era dependent.
A total of 266 patients underwent SKT (244 non-PSKT, 22 PSKT) in our center from 1985 to 2015. Association between PSKT and graft survival (allograft failure from any cause including death) was assessed with the use of Cox models.
During a median follow-up of 6.7 years, 116 events were recorded: 72 returns to dialysis and 44 deaths before return to dialysis. Survival curves diverged up to 5 years (5-year survivals: PSKT, 94.1 ± 5.7%; non-PSKT, 76.8 ± 2.9%) but they converged thereafter (12-year survivals: PSKT, 50.9 ± 15.2%; non-PSKT, 55.5 ± 3.9%). After adjustment for age and living-donor status, PSKT tended to be associated with better graft survival (hazard ratio [HR], 0.18; 95% confidence interval [CI], 0.02–1.27; P = .08) within the first 5 years of SKT but tended to be associated with worse outcome thereafter (HR, 2.36; 95% CI, 0.97–5.72; P = .06; P for interaction with time = .04). In addition, a significant interaction was identified between PSKT and SKT year (P for interaction = .04). In the multivariable model, the estimated HR for PSKT was 2.54 (95% CI, 0.88–7.35; P = .08) in 1990 as opposed to 0.16 (95% CI, 0.02–1.17; P = .07) in 2012.
The effect of PSKT on graft survival varies over time and according to year of the procedure. Although the benefit observed within the first 5 years of SKT appears to fade over time, overall graft survival seemingly improved in more recent years.

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13th Congress of the Catalan Transplantation SocietyKidney transplantationPre-Emptive Retransplantation in Patients With Chronic Kidney Graft Failure

Abstract

Introduction

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Kidney Int

Am J Kidney Dis

Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant

N Engl J Med

Coming back to dialysis after kidney transplant failure

Nephrol Dial Transplant

Evaluating the survival benefit of kidney retransplantation

Transplantation

13th Congress of the Catalan Transplantation Society
Kidney transplantation
Pre-Emptive Retransplantation in Patients With Chronic Kidney Graft Failure