Little data exists to guide the management of immunosuppression after renal graft failure. More aggressive tapering of immunosuppressive medications may reduce the risk of infection, but may increase the risk of rejection and sensitization. To document current practices in the US, we emailed a questionnaire to medical and surgical transplant directors as identified by the United Network for Organ Sharing. Emails were sent to 221 programs, of which 93 (42.1%) responded. 78.5% of respondents said that decisions on adjusting immunosuppression medications were made by the transplant center, but that only 24.7% reported using a standard protocol, with the majority reporting that practices are physician-dependent. The majority said that 80% or 100% of patients are off all immunosuppression one year after returning to dialysis. The most important factors cited in deciding whether to stop immunosuppression were plans to retransplant (40.2%) and signs and symptoms of rejection (37.0%). When asked which immunosuppressive medications are continued indefinitely, 21.5% responded prednisone and 71.0% said none. Respondents most commonly said they performed graft nephrectomy only if there are signs and symptoms of rejection (47.3%) or if signs and symptoms of rejection fail to respond to steroids (34.4%). We conclude that in the absence of good data to guide decisions on immunosuppression in patients with failed allografts, there is no standard practice in the US. However, our results suggest that over 70% of patients with failed grafts are taken completely off immunosuppression.

More data is needed to determine which policies lead to the best outcomes.

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