SP789MANAGEMENT OF IMMUNOSUPPRESSIVE THERAPY IN PATIENTS RETURNING TO DIALYSIS AFTER FAILURE OF RENAL TRANSPLANTATION. A MONOCENTRIC RETROSPECTIVE OBSERVATION

Abstract

INTRODUCTION: Kidney transplantation has become the preferred treatment for end-stage renal disease. However the increased number of transplanted patients results in reinstitution of dialysis in 4-5% of cases, because of allograft failure. Consensus guidelines for the management of this unique and frail patient sample are lacking. Clinical problems of the management of dialysis re-initiation include timing and choice of vascular access, immunosuppression prosecution vs discontinuation and indication to transplantectomy. There are few data in literature for clinician on the optimal management of immunosuppression following renal allograft failure. For these reasons, most centers have center-specific or patient-specific protocols. Although low dose-immunosuppression maintenance may preserve residual kidney function, long-term immunusoppressive theraphy favour malignancy, cardiovascular and infectious complications. Conversely immunosuppression discontinuation is associated to risks of rejection, transplant nephrectomy, adrenal insufficiency, immunological sensitisation. Transplantectomy would permit immunosuppression withdrawal, but the rate of morbidity and mortality (1.5-14% and 17-60%) is not negligible. METHODS: We retrospectively analysed 46 patients (43 renal and 3 combined kidneypancreas transplantation) with a failed kidney transplant returned to dialysis between Jan 2006-August 2017. Three patients returned twice due to failed re-transplant. RESULTS: Immunosuppressive drugs when re-starting dialysis were: prednisone (2.5-5 mg/day) in 34 patients, tacrolimus in 27 (trough levels 5.4±1.5 ng/ml), cyclosporine in 17 (trough levels 70.9±26.4 ng/ml), mycophenolate mofetil 500 mg/day in 7, sirolimus in 3 (trough levels 4.8±1.8 ng/ml), everolimus in 3 (trough levels 3.4±0.5 ng/ml), azathioprine 75 mg/die in one (Table 2) Nineteen patients underwent 21 transplantectomy (43.4%): 11 (52.3%) for chronic inflammatory state and histological findings of acute rejection, the remnant with the aim to achieve space in the pelvic fossa, acute pyelonephritis, post-transplant lymphoproliferative disorder or persistent hematuria. Surgical complication rate was 33.3%, mortality rate 0%. Figure 1 shows our algorithm for the management of immunosuppression after allograft failure. The resulted withdrawal time reported in table 3 is longer as compared to present protocol because it was fully applied only since 2010. CONCLUSIONS: Taking into account the lack of evidence-based recommendation, the low rejection rate observed after discontinuation of immunosupression and the relative safety of transplantectomy, we suggest to withdrawn immunosuppressive therapy within 6 months after dialysis restart in patients for whom a subsequent transplant is not feasible reserving transplantectomy to the case of acute rejection.