DETERMINANTS OF LATE ALLOGRAFT NEPHRECTOMY

When loss of graft function occurs more than six months after transpla ntation, allograft nephrectomy is not routinely performed at the time of graft failure. It is usually performed only on those patients who s ubsequently develop specific complications. However, little is known a bout the characteristics that make patients more likely to require all ograft nephrectomy. The purpose of our study was to identify risk fact ors for the subsequent need for allograft nephrectomy in patients with graft failure occurring more than 6 months after transplantation. For ty-one patients were studied, Inclusion criteria were: loss of graft f unction greater than or equal to 6 months after transplantation, resum ption of dialysis and initiation of weaning from immunosuppression, Th irty patients were treated with cyclosporine + prednisone +/- azathiop rine and 11 with azathioprine + prednisone. Mean follow-up time was 17 .8 months, ranging from 6 months to 6.1 years. Recipient age, sex and race! original renal disease, donor, donor source (cadaveric vs living related), HLA compatibility, levels of panel reactive antibodies, occ urrence of initial delayed graft function, causes of graft failure and tapering of immunosuppression were similar in patients with and witho ut allograft nephrectomy. Using univariate analysis, allograft nephrec tomy was found to be significantly more frequent in patients with a hi story of 2 or more episodes of acute rejection than in patients with n o rejection episode: 83% vs 30% (p = 0.03). In addition, allograft nep hrectomy was found to be significantly more frequent if the immunosupp ressive regimen included cyclosporine (62% vs 27.3%: p = 0.04). Using multivariate analysis however, the number of previous episodes of reje ction was found to be the only significant predictor for allograft nep hrectomy. None of the other variables considered in the multivariate a nalysis, including the type of immunosuppressive therapy, was identifi ed as a significant predictor for the need to perform allograft nephre ctomy. In summary, the need for late allograft nephrectomy was correla ted with the number of previous episodes of acute rejection. Patients with a history of numerous rejection episodes should thus be considere d more likely to require allograft nephrectomy once immunosuppression is withdrawn. Possible interventions to reduce or prevent the need for nephrectomy include more gradual tapering of immunosuppression at the time of graft failure or indefinite low-dose immunosuppressive therap y.