*Purpose: Patients with a failed renal allograft are at high risk for mortality. The potential benefit of maintaining immunosuppression with the intent to minimize sensitization must be balanced against the risk of complications. In the current era it remains unclear how to manage immunosuppression after graft failure in re-transplant candidates and clinical practices vary. Aim: To determine the association of immunosuppression maintenance and post failure outcomes including death, sensitization, and re-transplantation among patients with history of graft failure.

*Methods: We performed a single center retrospective study of patients transplanted from 10/2007 through 5/2017 who had graft failure (n=119). We collected data regarding basic demographics, immunosuppression, serial cPRA values, death, re-transplantation, and dialysis. JMPv13 was used for statistical analysis.

*Results: From 10/2007 through 5/2017, 1354 solitary ABO compatible transplants were performed and 119 of the transplants failed. Median (IQR) time to graft failure was 3.4 (1.4-5.3) years post-transplant. Of the graft failures, 9.2% (11/119) received a transplant prior to needing dialysis (preemptive) while 90.8% (108/119) started dialysis. Among the patients who started dialysis and had immunosuppression information, 45.8% (44/96) died and 20.1% (20/96) were re-transplanted over a median (IQR) follow-up of 1.3 (0.3-3.2) years of post-graft failure. Mortality and immunosuppression: Death occurred in 30.6% (11/36) of patients who discontinued immunosuppression versus 55.0% (33/60) in patients who continued immunosuppression, p=0.02. Mortality rates differed with age. Among patients aged < 65, 25.0% (8/32) died when immunosuppression was stopped and 47.8% (22/46) died when immunosuppression was maintained to some degree, p=0.04. The overall rate of death was higher in the patients aged > 65. In this group the death rate was similarly high regardless of immunosuppression [75.0% (3/4) versus 78.6% (11/14), p=0.87]. Overall, the factors associated with mortality on dialysis included immunosuppression maintenance (OR 2.8, p=0.02), female sex (OR 2.7, p =0.02), age >65 (OR 4.3, p=0.01) and Cardiovascular disease (OR 10.2, p<0.0001). Sensitization, re-transplantation, and immunosuppression: Complete immunosuppression withdrawal compared to maintenance was associated with a higher cPRA post graft failure [median 100 (IQR 94-100)] versus 65(12.5-96.5),p=0.02 but the re-transplantation rate was similar [22.2% (8/36) versus 20.0%(12/60), p=0.87].

*Conclusions: Immunosuppression maintenance after renal allograft failure is associated with increased mortality. Although withdrawal of immunosuppression is associated with increased sensitization, this does not appear to result in reduced transplantation. Therefore immunosuppression withdrawal should be considered among renal re-transplant candidates who are unlikely to receive a transplant within a short time period.

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