| Abstract|| |
Transplant nephrectomy (TN) is associated with significant morbidity and mortality and influences the outcome of subsequent renal transplantation. The aim of this study was to identify the reasons for TN in a single transplant center in the United Kingdom and to determine the complication rate, effect on relisting and re-transplantation. We studied all the TNs in our center from January 2000 to December 2011. Detailed information including cause of allograft failure and reason for TN were analyzed. Of 602 renal transplants performed at our center during the period of the study, 42 TNs were performed on 38 (6%) patients (24 men and 14 women). The median age of the patients at the time of transplantation who subsequently underwent TN was 56 years (range: 28-73 years) and 71% of the allografts were donated after circulatory death. The mean human leucocyte antigen mismatch for these patients was 2.3. The most commonly used immunosuppression was a combination of prednisolone, mycophenolate and tacrolimus, which was used in 50% of the patients. Twenty-five (60%) of the TNs in this series were for allografts failing during the first month of transplantation. The most common indication for the TN was graft thrombosis (50%), with an overall in-hospital mortality rate of 9.5% and a morbidity rate of 31%. Seven of 19 patients listed underwent successful re-transplantation. Although TN is associated with a risk of significant morbidity and mortality, it does not preclude from listing for re-transplantation. The difficulty of access to complete information about transplant failures and TN highlights the need for a national registry.
|How to cite this article:|
Ariyarathenam A, Bamford A, Akoh JA. Transplant nephrectomy - A single-center experience. Saudi J Kidney Dis Transpl 2015;26:1108-12
|How to cite this URL:|
Ariyarathenam A, Bamford A, Akoh JA. Transplant nephrectomy - A single-center experience. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2018 Jan 20];26:1108-12. Available from: http://www.sjkdt.org/text.asp?2015/26/6/1108/168557
| Introduction|| |
Kidney transplantation remains the optimal choice in improving survival of patients with established renal failure. , About 70,000 renal transplants are performed worldwide in over 80 countries annually. Of these, an estimated 7-10% fail during the first year, and a further 3-5% fail every year thereafter. , Following allograft failure, the indications for transplant nephrectomy (TN) remain controversial due to the associated risks of morbidity and mortality. Furthermore, TN has complex effects on patients' well-being, chance of re-transplantation and outcome of re-transplantation. About 20% of patients on the waiting list for renal transplantation in the United States underwent TN,  but the rate is not known in the UK.
The aim of this study was to identify the reasons for allograft nephrectomy in a single transplant center in the United Kingdom and to determine the complication rate and effect on relisting and re-transplantation.
| Patients and Methods|| |
We retrospectively studied all the patients who underwent TN in a single regional transplant center in the UK between January 2000 and December 2011. Patients who underwent TN were identified using a combination of computer database (PROTON information system, Clinical Computing, PLC, London, England), manual card index and the operating room records of all the performed TNs. Detailed information included donors characteristics, recipients gender and age at transplantation, duration of allograft function, causes of allograft failure and reasons for TN. The data were entered in an Excel database and analyzed.
| Results|| |
A total of 602 renal transplants were performed during the study period. Although the numbers of transplant failures were not known, 42 TNs were performed on 38 patients (24 males and 14 females) with a median age of 56 years (range: 28-73 years) at the time of transplantation. In terms of co-morbidities, 23 (61%) patients suffered from hypertension and ischemic heart disease and cerebrovascular disease, six (16%) patients were current or ex-smokers and four (11%) patients were diabetic, while three patients had previously failed retained transplants. The average body mass index of the 42 patients at the time of index transplantation was 26.5 (range 19.5-40 kg/m 2 ).
Of the 42 patients undergoing TN, the allografts were retrieved from donation after circulatory death (DCD) in 30 (71%) cases, living donation in six (14%) cases, donation after brain death (DBD) in four (10%) cases and undocumented in two (5%) others. The mean human leucocyte antigen (HLA) mismatch for these patients was 2.3.
The most frequently used immunosuppression regime prior to the year 2005 (17 cases) was a combination of prednisolone and cyclosporine with either azathioprine (nine cases) or mycophenolate mofetil (eight cases). After 2005, cyclosporine was replaced with tacrolimus hence rendering a combination of prednisolone, tacrolimus and mycophenolate mofetil (22 cases), the preferred immunosuppression regime.
Eighteen (43%) of the TNs in this series were for allografts that failed in the first week of transplantation. Of the remaining, seven (17%) failed between one and four weeks, ten (24%) between one month and 12 months and seven (17%) thereafter.
The most common indication for TN was graft thrombosis (21 cases). This was either due to venous thrombosis (16 cases), arterial thrombosis (three cases) or both arterial and venous thrombosis (two cases). Other reasons for TN were biopsy proven, refractory acute allograft rejection (ten cases) or primary nonfunction due to donor vascular disease (three cases). Pain despite immunosuppression, mycotic aneurysm of the transplant artery and severe acute cortical necrosis possibly due to thrombotic microscopic angiopathy constituted a case each as indications for TN.
Thirteen patients had one or more complications producing a morbidity rate of 31% [Table 1]. Four patients died post-TN, contributing an overall in-hospital mortality rate of 9.5%. The first patient, aged 59 years, received a kidney from a 64-year-old DBD with no HLA mismatch. He underwent TN four days post-transplantation due to renal vein thrombosis and died 22 days post-procedure from multiple organ system failure. A post-mortem examination established the cause of death as small bowel infarction of unknown cause.
The second patient was 61 years old when she was transplanted a DCD kidney from a 55-year-old donor with three HLA mismatches. She underwent TN 19 days post-transplantation due to refractory acute allograft rejection and died from pulmonary embolism at three months post-TN. The third patient, aged 59 years, successfully underwent a re-transplantation following a previous TN. His transplant functioned for 3.5 years prior to his TN for refractory Type 2A rejection. He died three months post-nephrectomy due to ischemic heart failure. The fourth patient, aged 73 years, received a kidney from a 49-year-old DCD in 2011 with three HLA mismatches. TN was undertaken six weeks post-transplantation for severe sepsis as the kidney was encased in about 1000 mL of thick pus and 1-2 mm defect to the Carrel's patch was repaired. The patient subsequently died three days post-trans-nephrectomy due to severe hemorrhage, which was confirmed at post-mortem to have risen from the external iliac artery, distal to the anastomosis, with an intact repair of the Carrel's patch. This last case of mortality is the only one that appears to be directly related to the TN procedure.
The outcome of patients post-TN are summarized in [Figure 1]. Eleven of 19 (57%) patients underwent re-transplantation (seven were successful transplants and four were unsuccessful). Of the eight patients who were not relisted after TN, six were still alive on dialysis at the conclusion of the study with mean duration of 23 months from time of TN (range 2-41 months).
|Figure 1: Summary of the outcome of the patients post-transplant nephrectomy.|
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| Discussion|| |
The increase in the number of renal transplants performed annually worldwide has resulted in an increased number of patients returning to dialysis following transplant failure. There are no current universally accepted guidelines for the management of patients with failed renal transplants, leading to a large variation in the cumulative TN rates (0.5- 80%) cited in the literature, ,,, largely depending on the policy of the individual transplant centers. In our center, the policy is to perform TN on early graft failures, whereas late failed grafts are only removed in symptomatic patients.
The most common indication for TN in our study was graft thrombosis. This might be attributed to technical difficulties encountered at the time of transplantation. All our patients underwent thrombosis risk assessment, received low-dose heparin prophylaxis and long-term aspirin 75 mg daily and were treated with anticoagulation in line with the prevailing hospital policy.
The likelihood of TN is dependent on the time of allograft failure after transplantation, with early graft failure more likely to result in TN. , This is supported by the data from the National Health Service Blood and Transplant (NHSBT) in UK, which shows a TN rate of 41% for allografts failing during the first three months compared with 23% during three to <12 months, 9% during 12 to <24 months and 4% after two years.  This is consistent with our data, where 60% of the TNs were performed in patients whose grafts failed within one month of transplantation, with the majority occurring within one week post-transplantation.
The indications and timings of TN for a failed allograft remains heavily debated in the current literature. The best course of action for the group of patients who have failed asymptomatic allografts either awaiting re-transplantation or destined for life-long dialysis remains to be established. The presence of a failed allograft may require long-term, low-dose immunosuppression to avoid chronic inflammatory response leading to an increase in C-reactive protein, erythrocyte sedimentation rate, erythropoietin resistance, hypoalbuminemia and malnutrition. ,, The long-term immunosuppression along with the increased risk of infection and the potential for malignancy are the arguments in favor of offering a preemptive elective TN. , This was strongly supported by Ayus et al,  who reported that the patients who underwent TN for failed allografts showed improved survival compared with those with failed retained allografts. However, as indicated by Schaefer and Helderman,  a significant limitation of the study of Ayus et al was the predominance of younger patients with fewer co-morbidities in their population. Such a selection bias indicates that their results should be interpreted with caution. The high morbidity (17-60%) and mortality rates (1.5-14%), which was even higher in the pre-cyclosporine era (7.3- 38.7%), adds to the caution of offering preemptive nephrectomy for failed allografts in this high-risk patient group. ,,,, Another argument is that TN results in sensitization and hence increased panel-reactive antibodies, especially in patients whose graft survival was >12 months, and this may be associated with an increased risk of repeat transplant failure. , This study has important limitations. Firstly, it is a retrospective analysis of a small transplant cohort and even smaller TN patients. This limits the study from arriving at a conclusive decision on the risks versus the benefits of TN. Secondly, the inadequate data on the patients who were transferred back to their referring district general hospitals, where they probably recommenced on renal replacement therapy without re-referral back to our center either due to patient unsuitability, patient choice not to undergo further surgery or migration to another renal transplant catchment area. Thirdly, a significant limitation refers to the lack or inadequate data on the patients with allograft failure not undergoing TN.
We conclude from our study that TN is not without significant morbidity and mortality. It is therefore reasonable to adopt the pragmatic approach of removing early failing grafts and complicated late failing ones. There is a need for more detailed prospective, randomized studies to illustrate the effect of TN on re-transplantation. Furthermore, a centralized data registry dedicated at the NHSBT for patients undergoing TN may be helpful in this regard.
| Acknowledgments|| |
These data were presented as a poster at the Joint British Transplant Society and Renal Associated congress (BTSRA), Bournemouth, England, March 2013.
Conflict of Interest
The authors declare that there is no conflict of interests regarding the publication of this article.
| References|| |
Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in end-stage renal failure: Evidence for reduced mortality risk compared with hemodialysis during long-term follow-up. J Am Soc Nephrol 1998;9:2135-41.
Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725-30.
Akoh JA. Transplant nephrectomy. World J Transplant 2011;1:4-12.
Garcia Garcia G, Harden P, Chapman J; World Kidney Day Steering Committee. The global role of kidney transplantation. J Nephrol 2012; 25:1-6.
Perl J, Bargman JM, Davies SJ, Jassal SV. Clinical outcomes after failed renal transplantation - Does dialysis modality matter? Semin Dial 2008;21:239-44.
Goldfarb-Rumyantzev AS, Hurdle JF, Baird BC, et al. The role of pre-emptive re-transplant in graft and recipient outcome. Nephrol Dial Transplant 2006;21:1355-64.
Ahmad N, Ahmed K, Mamode N. Does nephrectomy of failed allograft influence graft survival after re-transplantation? Nephrol Dial Transplant 2009;24:639-42.
Lucarelli G, Vavallo A, Bettocchi C, et al. Impact of transplant nephrectomy on retransplantation: A single-center retrospective study. World J Urol 2013;31:959-63.
Johnston O, Rose C, Landsberg D, Gourlay WA, Gill JS. Nephrectomy after transplant failure: Current practice and outcomes. Am J Transplant 2007;7:1961-7.
Zerouali F, Levtchenko EN, Feitz WF, Cornelissen EA, Monnens LA. Renal transplant nephrectomy in children: Can an aggressive approach be recommended? Pediatr Transplant 2004;8:561-4.
Bond M, Pitt M, Akoh J, Moxham T, Hoyle M, Anderson R. The effectiveness and costeffectiveness of methods of storing donated kidneys from deceased donors: A systematic review and economic model. Health Technol Assess 2009;13:iii-iv, xi-xiv, 1-156.
López-Gómez JM, Pérez-Flores I, Jofré R, et al. Presence of a failed kidney transplant in patients who are on hemodialysis is associated with chronic inflammatory state and erythropoietin resistance. J Am Soc Nephrol 2004; 15:2494-501.
Ayus JC, Achinger SG. At the peril of dialysis patients: Ignoring the failed transplant. Semin Dial 2005;18:180-4.
Schleicher C, Wolters H, Kebschull L, et al. Impact of failed allograft nephrectomy on initial function and graft survival after kidney retransplantation. Transpl Int 2011;24:284-91.
Toledo-Pereyra LH, Gordon C, Kaufmann R, Whitten JI, Mittal VK. Role of immediate versus delayed nephrectomy for failed renal transplants. Am Surg 1987;53:534-6.
Ayus JC, Achinger SG, Lee S, Sayegh MH, Go AS. Transplant nephrectomy improves survival following a failed renal allograft. J Am Soc Nephrol 2010;21:374-80.
Schaefer HM, Helderman JH. Allograft nephrectomy after transplant failure: Should it be performed in all patients returning to dialysis? J Am Soc Nephrol 2010;21:207-8.
Sharma DK, Pandey AP, Nath V, Gopalakrishnan G. Allograft nephrectomy - A 16-year experience. Br J Urol 1989;64:122-4.
Mazzucchi E, Nahas WC, Antonopoulos IM, Piovesan AC, Ianhez LE, Arap S. Surgical complications of graft nephrectomy in the modern transplant era. J Urol 2003;170:734-7.
Jacob A Akoh
South West Transplant Center, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8DH