Transplant nephrectomy improves survival following a failed renal allograft. J Am Soc Nephrol 21: 324–380, 2010

There is a lack of consensus among transplant physicians regarding the optimal management of the large number of patients who return to dialysis (approximately 2000 per year) with a failed kidney transplant (1–3). The high rate of morbidity and mortality experienced by patients after primary kidney transplant failure exceeds those observed in dialysis patients who are awaiting kidney transplantation (4–7).

Dialysis patients with failed previous transplants have been shown to have a standardized mortality ratio of 1.35 compared with dialysis patients who have never received a renal transplant (8). Several predictors of patient survival after allograft failure have been identified, such as age, diabetes, HLA matching, gender, and first transplant donor type (1,9). Mortality after primary allograft failure is strongly influenced by the type of ESRD, the highest rate found among patients with type 1 diabetes compared with either type 2 diabetes or other causes of ESRD (1).

The reasons for the poor survival after graft failure have remained elusive. The triggering of an inflammatory process by the retained allograft (characterized by hypoalbuminemia, erythropoietin resistance, high ferritin, and elevated C-reactive protein) and an increased incidence of infectious and cardiac complications as a result of ongoing immunosuppression have been observed but not yet confirmed by controlled clinical studies (10–12).

The goal of this observational study was to evaluate the impact of transplant nephrectomy on the survival of patients who return to dialysis after kidney transplant failure. Using the US Renal Data System, the authors identified and analyzed a cohort of patients (n = 10,951) who returned to dialysis (hemodialysis and peritoneal dialysis) during a 10-year period spanning from January 1994 through December 2004.