Patients After Kidney Allograft Failure: Immunologic and Nonimmunologic Considerations

•Patients returning to dialysis after kidney transplant failure comprise a special group accounting for approximately 5%–15% of the hemodialysis population.•Exposure to immunologic and nonimmunologic factors leads to high all-cause mortality in this patient population.•Optimal management including proper time of dialysis initiation, immunosuppression tapering, nephrectomy under certain conditions, and retransplantation are important factors of patient survival.

Patients returning to dialysis after kidney transplant failure represent approximately 5%–15% of the population starting hemodialysis. These patients exhibit a high risk of morbidity and mortality attributed mainly to the exposure to immunosuppressive medications and to a uremic environment. The purpose of this paper was to review data regarding survival after renal allograft failure and the optimal management of patients before returning to dialysis. Moreover, issues surrounding nephrectomy after renal allograft failure, the tapering of immunosuppression and the possibility of retransplantation are examined, because they seem to be crucial for patient survival and the quality of life.