Year : 2008 | Volume
: 19 | Issue : 1 | Page : 59--61
Outcome of Patients without any Immunosuppressive Therapy after Renal Allograft Failure
Afsoon Emami Naini, Ali Amini Harandi, Pooya Daemi, Rozbeh Kosari, Manochehr Gharavi
Department of Nephrology, Khorshid Hospital, Isfahan University of Medical Sciences and Health Services, Isfahan, Iran
Afsoon Emami Naini
Department of Nephrology, Khorshid Hospital, Isfahan University of Medical Sciences and Health Services, Isfahan
Continuation of low-dose maintenance immunosuppressive therapy in endstage renal allografts (ESRAs) that are left in situ is controversial. We studied the outcome of 85 patients (mean age 33.3 ± 13.4 and range of 12-56 years) on hemodialysis with ESRAs, and without immunosuppressive therapy in our center from July 1991 to July 2003. Twelve (14.1%) study patients underwent allograft nephrectomy within a mean interval of 44.5 months after graft failure. The rest of the patients remained stable without fever, hematuria, graft tenderness, or localized edema during a mean interval of 46.5 ± 45.2 months of follow-up. These results are promising and suggest that maintenance immunosuppressive therapy in patients with ESRAs and on dialysis may not be necessary to avoid allograft nephrectomy. Prospective studies are warranted to substantiate these results.
|How to cite this article:|
Naini AE, Harandi AA, Daemi P, Kosari R, Gharavi M. Outcome of Patients without any Immunosuppressive Therapy after Renal Allograft Failure.Saudi J Kidney Dis Transpl 2008;19:59-61
|How to cite this URL:|
Naini AE, Harandi AA, Daemi P, Kosari R, Gharavi M. Outcome of Patients without any Immunosuppressive Therapy after Renal Allograft Failure. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Sep 22 ];19:59-61
Available from: http://www.sjkdt.org/text.asp?2008/19/1/59/37434
There are various strategies for the management of maintenance immunosuppressive therapy in patients who return to hemodialysis or peritoneal dialysis with end-stage renal allografts (ESRAs). The strategies include early discontinuation of immunosuppressive drugs  followed by removal of the ESRAs,  or continuation of low-dose maintenance immunosuppressive therapy to avoid rejections and maintain residual diuresis. ,, The continuation of low dose maintenance immunosuppressive therapy in ESRAs that are left in situ is controversial ,,, and there are scarcity of studies on this subject. Some studies recommended discontinuation of immunosuppressive therapy,  while others recommended continuation of immunosuppression for the ESRAs that may postpone or prevent the need for nephrectomy and they suggest prolonged or gradual tapering immunosuppression. ,
Considering the benefit of retaining ESRAs in situ and with existence of serious adverse effects related to immunosuppressive medication, we aim in our study to determine whether discontinuation of immunosuppressive therapy might have adverse effect on accelerating the necessity for ESRA nephrectomy.
Method and Materials
We retrospectively studied all patients who were maintained on chronic hemodialysis due to ESRAs, and underwent the first living kidney transplantation in transplant centers in Isfahan, Iran from July 1991 to July 2003. we included in the study the patients in whom the immunosuppressive therapy was discontinued after graft failure, and excluded the re-transplanted patients, and the ones who died with a any related or not related cause to the underlying renal disease.
We analyzed the patients' demographic data, and the interval from the date of graft failure to the date of nephrectomy or the end of observation period, March 2004. The reasons of nephrectomy included fever, hematuria, graft tenderness, localized edema, and severe hypertension.  Immunosuppressive medication protocol consisted of prednisolone, cyclosporine A, azathioprine or mycophenolate mofetil. These medications were tapered immediately after graft failure in all patients.
There were 85 patients who fulfilled the criteria of study. They all were residents in Isfahan province. The mean age of the patients was 33.3 ± 13.4 (ranged from 12 to 56 years), and 50 (58.8%) patients were males. All the patients had living donated allografts, and panel reaction antibody (PRA) less than 5 percent before transplantation. The mean previous transfusion history was 2.4 times per patient. Primary diseases were glomerulonephritis, diabetes mellitus, urological and hypertension with frequency of 22(25.8%), 17 (20.0%), 14(16.4%) and 6(7.0%), respecttively. Polycystic kidney disease (PKD) and Alport's syndrome were reported in one patient each. There were 24(28.2%) study patients with unknown causes of primary kidney disease.
Twelve (14.1%) study patients underwent allograft nephrectomy within a mean interval of 44.5 months after graft failure. The rest of the patients remained stable without fever, hematuria, pain, graft tenderness, or localized edema during a mean interval of 46.5 ± 45.2 months of follow-up (median: 43 months, and range: 7-132 months).
The promising results of our study suggest that continuation of maintenance immunosuppressive therapy in patients on hemodialysis with ESRAs may not delay the need for nephrectomy. Gregoor et al, reported that very low-dose immunosuppression might not be sufficient to suppress reactive antibodies, and further rejection. They concluded that there might be no benefit of continuing low-dose immunosuppressive therapy to prevent further rejection in ESRAs. 
Benefits of unremoved ESRAs such as residual diuresis, remaining clearance, and urine output during hemodialysis or peritoneal dialysis, were counter balanced in our decision making by the increased risk of morbidity and mortality due to infection and malignancies secondary to continued exposure to the immunosuppressive agents. Considering the low rate of nephrectomy in our study (14%), it seemed more rational to discontinue the maintenance immunosuppressive therapy. However, little is known about the characteristics that make patients more likely to require allograft nephrectomy. 
Unfortunately, our study had some restricttions. We did not have any control groups for comparison. Furthermore, the different length of follow-up period in these cases did not allow the use of complementary methods of data analysis.
We conclude that our study is promising and suggests that maintenance immunosuppressive therapy in patients with ESRAs and on dialysis may not be necessary to avoid allograft nephrectomy. Prospective studies are warranted to substantiate these results.
|1||Vanrenterghem Y, Khamis S. The management of the failed renal allograft. Nephrol Dial Transplant 1996;11: 955-7.|
|2||Glicklich D, Greenstein SM, Posner L, Schechner RS, Tellis VA. Transplant nephrectomy in the cyclosporine era. J Am Soc Nephrol 1993;4:937.|
|3||Gallo CD, Grino JM, Seron D, Castelao AM, Franco E, Alsina J. Routine allograft nephrectomy in late renal failure. Transplantation 1990;44:1204.|
|4||Kiberd BA, Belitsky P. The fate of the failed renal transplant. Transplantation 1995; 59:645.|
|5||Jassal SV, Lok CE, Walele A, Bargman JM. Continued transplant immunosuppression may prolong survival after return to peritoneal dialysis: Results of a decision analysis. Am J Kidney Dis 2002;40:178-83.|
|6||O'Sullivan DC, Murphy DM, McLean P, Donovan MG. Transplant nephrectomy over 20 years: Factors involved in associated morbidity and mortality. J Urol 1994;151: 855-8.|
|7||Silberman H, Fitzgibbons TJ, Butler J, Berne TV. Renal allografts retained in situ after failure. Arch Surg 1980;115:42-3.|
|8||Secin FP, Rovegno AR, del Rosario Brunet M, Marrugat RE, Davalos Michel M, Fernandez H. Cumulative incidence, indications, morbidity and mortality of transplant nephrectomy and the most appropriate time for graft removal: Only nonfunctioning transplants that cause intractable complications should be excised. J Urol 2003;169:1242-6.|
|9||Schaubel DE, Jeffery JR, Mao Y, Semenciw R, Yeates K, Fenton SS. Trends in mortality and graft failure for renal transplant patients. CMAJ 2002;167:137-42|
|10||Smak Gregoor PJ, Zietse R, van Saase JL, et al. Immunosuppression should be stopped in patients with renal allograft failure. Clin Transplant 2001;15:397-401.|
|11||Madore F, Hebert MJ, Leblanc M, et al. Determinants of late allograft nephrectomy. Clin Nephrol 1995;44:284-9.|
|12||Hansen BL, Rohr N, Svendsen V, Birkeland SA. Graft failure and graft nephrectomy without severe complications. Nephrol Dial Transplant 1987;2:189-90.|