Patient outcomes after kidney allograft loss

Despite considerable advances in immunosuppression and in short-term graft survival, little improvement has been observed in long-term survival rates. About 30% of patients lose their graft in the first 5 years, and this percentage increases up to 50% at 10 years. Graft losses, due to causes other than death with functioning graft, are an important cause of end-stage renal disease. Patients with failed graft account for 4% to 10% of those admitted yearly for dialysis therapy. There is no evidence about the superiority of hemodialysis or peritoneal dialysis in the treatment of these patients. Graft failure seems to be an important risk factor associated with morbidity and mortality, mostly in the first months after restarting dialysis. The causes of these high morbidity and mortality rates are not very well known. However, a poor control of the chronic kidney disease complications, the persistence of a chronic inflammatory state due to the failed graft, and the lack of a protective effect of the functioning graft could play an important role. This inflammatory state could be mediated by the presence of the rejected graft, and nephrectomy has been recommended. A variable number of patients with failed graft are relisted for a new transplant, thus increasing the shortage of organs. Graft survival of repeat transplantation with the new immunosuppressive regimens is very close to that of first-graft survival. Moreover, retransplantation increases patient survival rates in some series when compared with patients on dialysis. Complications during the first transplant such as BK virus nephropathy or lymphoproliferative diseases do not necessarily recur after the repeat transplant.