Management of chronic renal allograft dysfunction and when to re-transplant

Richard J Baker,Stephen D Marks

doi:10.1007/s00467-018-4000-9

Abstract

Despite the advances in renal transplantation over the last decades, chronic allograft dysfunction remains the largest concern for patients, their families, clinicians and other members of the multi-disciplinary team. Although we have made progress in improving patient and renal allograft survival within the first year after transplantation, the rate of transplant failure with requirement for commencement of dialysis or re-transplantation has essentially remained unchanged. It is important that paediatric and adult nephrologists and transplant surgeons, not only manage their patients and their renal transplants but provide the best chronic kidney disease management during the time of decline of renal allograft function. The gold standard for patients with Stage V chronic kidney disease is to have pre-emptive living donor transplants, where possible and the same is true for healthy renal transplant recipients with declining renal allograft function. The consideration for children and young people as they embark on their end-stage kidney disease journey is the risk-benefit profile of giving the best immunologically matched and good quality renal allografts as they may require multiple renal transplantation operations during their lifetime.

Highlights

Transplant professionals often exhort their colleagues to consider pre-emptive renal transplantation as the primary form of renal replacement therapy, preferably with a living donor
Report, published annually by NHS Blood and Transplant (NHSBT), there is a paucity of data on re-transplantation rates since they are not included in the UK Renal Registry (UKRR) annual report
The consideration for children and young people as they embark on their end-stage kidney disease journey is the riskbenefit profile of giving the best immunologically matched and good quality renal allografts as they may require multiple renal transplantation operations during their lifetime

Summary

Introduction

Transplant professionals often exhort their colleagues to consider pre-emptive renal transplantation as the primary form of renal replacement therapy, preferably with a living donor. These results suggest that if a second transplant is likely to occur within 12 months (e.g. live donor or high priority deceased donor renal transplant after early failure) immunosuppressive therapy should be maintained This is a complex clinical decision due to the infection risks on dialysis therapy and should be made according to individual circumstances by the transplant team in a timely fashion and documented before the initiation of renal replacement therapy. There is a wide body of evidence to suggest that patient management is suboptimal at this time with relatively low achievement of simple targets laid out in guidelines It is incumbent upon the transplant community to recognise and treat advanced CKD effectively in RTR and engage in shared decision making to choose options for further renal replacement therapy.

Which of the following is true related to transplant nephrectomy?

Findings

Compliance with ethical standards