During the last two decades the number of recipients (KTRs) of a previous kidney transplantation being evaluated and waitlisted for a subsequent kidney transplantation has disproportionately increased to almost 25% of all waitlisted patients. Evidence for the optimal management of the failed first kidney allograft with respect to nephrectomy remains inconsistent and controversially discussed.

We studied 165 KTRs, who underwent their second kidney transplantation from 1998 to 2015. In 99 of 165 KTRs (60%) the failed first kidney allograft was removed before retransplantation, and in 66 of 165 (40%) the first kidney allograft was retained in situ. KTRs were divided into those with a first kidney allograft loss due to immunological factors and those due to non-immunological factors. Samples were collected before transplantation, at +1, +2, and +3 months posttransplantation and alloreactive T-cells were measured using an interferon-γ Elispot assay.

KTRs with nephrectomy of the failed kidney allograft show comparable patient survival compared with KTRs without nephrectomy, but a higher incidence of death from sepsis in the early posttransplant period. Among KTRs with a non-immunological loss of the previous allograft, KTRs without nephrectomy show superior death-censored allograft survival and function, less acute cellular rejection, and lower frequencies of alloreactive T-cells pre- and posttransplantation compared to KTRs with nephrectomy (p<0.05). No differences, however, were observed for delayed graft function, the presence of preformed PRAs, and de novo DSAs compared to KTRs with nephrectomy (p<0.05). KTRs with an immunological loss of the previous allograft show significantly inferior death-censored allograft survival compared to those with a non-immunological cause of allograft loss (p=0.028). KTRs with the first kidney allograft retained in situ show a higher incidence of BK viremia compared to KTRs with nephrectomy of the previous allograft (p<0.05).

Our results suggest superior allograft outcomes in KTRs with the first kidney allograft retained in situ after a non-immunological loss of the allograft. The observed lower alloreactivity may contribute to the observed excellent allograft outcomes. The presence of a failed allograft kidney may serve as origin for BK viremia.

CITATION INFORMATION: Schachtner T, Stein M, Reinke P. Nephrectomy of the Failed First Kidney Allograft Predisposes Kidney Transplant Recipients to Presensitization with Alloreactive T-Cells and Inferior Allograft Survival After Retransplantation. Am J Transplant. 2017;17 (suppl 3).

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