What are the steps to manage graft failure?

Management of Kidney Allograft Failure

Managing kidney allograft failure requires a systematic approach centered on early identification, coordinated multidisciplinary care, strategic immunosuppression adjustment, and timely preparation for kidney replacement therapy or retransplantation. 1

Initial Assessment and Communication

When eGFR declines to ≤20 ml/min per 1.73 m² or rapid irreversible decline occurs at any eGFR level, immediately initiate communication with the dialysis team and begin transition planning. 1 This threshold represents the critical window for intervention and preparation, regardless of whether the patient is a retransplant candidate.

Begin modality counseling immediately at this stage, including discussion of different dialysis options, retransplantation possibilities (preemptive if living donor available), and conservative/palliative care when appropriate. 1

Multidisciplinary Care Coordination

Establish care through either:

• Referral to a general nephrology multidisciplinary clinic (MDC) with expertise in imminent dialysis needs, OR
• Enhanced transplant clinic with providers capable of managing transition to next treatment modality 1

The MDC team must include nephrologists, social workers, dieticians, healthcare navigators, and emotional support staff. 1 Access to clinical psychology is strongly recommended given the psychological vulnerability during this period. 1

Critical pitfall to avoid: Do not blame patients for graft failure even if medication nonadherence contributed—maintain a supportive approach throughout. 1

Immunosuppression Management Strategy

For Retransplant Candidates with Residual Function (Not Yet on Dialysis)

Maintain immunosuppression to preserve residual kidney function and urine output. 1

• Continue calcineurin inhibitor (CNI) at low therapeutic range to minimize new donor-specific antibody (DSA) development 1
• Monitor CNI trough levels closely and adjust for side effects 1
• Consider reducing antimetabolite by 50% to decrease complications while maintaining CNI 1
• Maintain low-dose corticosteroids 1

For Patients on Dialysis After Graft Failure

Implement a staged immunosuppression taper over 12 months based on retransplant candidacy: 1

At dialysis initiation:

• Reduce antimetabolite by 50%
• Maintain CNI ± low-dose prednisone 1

At 3 months post-dialysis:

• Stop antimetabolite completely
• Maintain low-dose CNI ± low-dose prednisone 1

At 6 months post-dialysis:

• Reduce CNI by 50%
• Continue low-dose prednisone 1

At 9-12 months post-dialysis:

• Consider additional CNI reduction or cessation of all immunosuppression if no graft intolerance syndrome and no significant increase in calculated panel reactive antibody (CPRA) 1

Critical consideration: Corticosteroids should be the last medication tapered due to adrenal dependency—taper slowly over the first 6 months after graft failure to avoid hypocortisolism. 1

For Non-Retransplant Candidates

Taper immunosuppression more aggressively, particularly in patients with severe complications, infections, or malignancies. 1 Once graft function ceases on dialysis, maintain only corticosteroids initially and taper as the last medication. 1

Dialysis Access Planning

Place arteriovenous (AV) access when eGFR approaches 20 ml/min per 1.73 m² if no living donor is available for preemptive retransplantation. 1

• Patients should protect existing AV fistulas after transplantation, as prior access often fails over time 1
• No evidence supports routine access maintenance procedures (angioplasty, stenting) with nephrotoxic dye exposure in transplant recipients 1
• For retransplant candidates with established surgical dates for living-donor transplant, short-term dialysis via tunneled catheter is acceptable 1

Timing of dialysis initiation should be based on clinical factors and symptoms rather than eGFR alone. 1

Retransplantation Planning

Encourage identification of potential living donors immediately to maximize preemptive retransplantation opportunities. 1 However, listing for retransplantation should never be conditional on having potential living donors. 1

• Establish baseline panel reactive antibody (PRA) value when eGFR approaches 20 ml/min 1
• Monitor CPRA every 3-6 months while wait-listed 1
• Optimize wait-list management strategies to decrease time to transplantation 1

Allograft Nephrectomy Indications

Perform allograft nephrectomy only for specific clinical indications: 1

• Graft intolerance syndrome (hematuria, abdominal pain, fever, failure to thrive, or source of infection) unresponsive to immunosuppression 1
• Renal vein or renal artery thrombosis with graft infarction and risk of rupture 1
• Severe acute rejection unresponsive to bolus corticosteroids with pain and hemorrhage 1
• Severe anemia and chronic inflammation refractory to medical management 1

Important caveat: Evidence regarding nephrectomy's effect on HLA sensitization is conflicting—weigh risks and benefits carefully. 1

Chronic Kidney Disease Management

Manage CKD complications according to severity for non-transplant patients: 1

• Blood pressure control
• Anemia management
• Proteinuria treatment
• Secondary hyperparathyroidism management
• Routine malignancy surveillance 1

Communication and Patient Education

Confirm the accepting dialysis unit understands the transition plan and verify patient comprehension. 1 Develop better educational tools including videos, webinars, and brochures with peer support incorporated. 1

Allow adequate time for patients to accept and prepare for transition away from functioning-transplant health state. 1 Educate clinicians about conservative/palliative care options that assist through transition periods, not simply at end of life. 1