P277
TRANSPLANT NEPHRECTOMY FOLLOWING GRAFT FAILURE: WHO GETS IT
AND DOES IT MAKE A DIFFERENCE?
Thomson, P, Clancy, M, Geddes, C
Renal Unit, Western Infirmary, Glasgow
INTRODUCTION: Transplant nephrectomy is not routinely conducted following graft
failure although is often performed soon after a return to dialysis due to acute illness or later,
in the context of a chronic inflammatory illness related to transplant rejection. The aim of
this study was to identify the proportion of patients who undergo transplant nephrectomy
following a return to dialysis and compare their clinical characteristics and outcomes to those
in whom the transplant was left in-situ.
METHODS: We identified all patients who attended our renal transplant unit between
01/01/1968 and 01/08/2009, were registered on the unitary electronic patient record (EPR)
and were noted to have a failed renal transplant. Baseline clinical, laboratory and
demographic data were recorded. These included age, sex, primary renal diagnosis, date of
transplant, type of transplant, date of transplant failure, cause of transplant failure and
whether transplant nephrectomy was undertaken. Duration of follow-up within the renal unit
and subsequent mortality were recorded. Comparison of nephrectomy and non-nephrectomy
groups was made by univariate parametric and non-parametric testing with significance level
set at <0.05.
RESULTS: A total of 774 patients experienced 994 episodes of renal transplant failure
between 01/01/1968 and 01/08/2009. 468/774 (60.1%) of patients were male with a mean
age at first transplant of 35.9yrs.
A total of 919/994 (92.4%) failed transplants were from cadaveric donors whilst 75/994
(7.6%) were from live donors. 384/994 (38.6%) episodes of transplant failure were followed
by transplant nephrectomy. 223/384 (58.1%) nephrectomies occurred within 4 weeks of
transplant failure with 21/384 (5.5%) occurring >52 weeks after failure.
Discounting those patients with transplant nephrectomy within 4 weeks of failure, those who
subsequently underwent transplant nephrectomy were found to be similar in age at
transplantation (33.4yrs v 33.3yrs, p=0.95), duration of renal transplant (5.1yrs v 4.6yrs,
p=0.32), rates of transplant rejection causing failure (42.1% v 36.9%, p=0.26) and rates of
mortality (13.4yrs v 14.5yrs, p=0.585) to those in whom the transplant was left in-situ.
Transplant nephrectomy was found to occur more commonly in patients with chronic
allograft nephropathy (7.1% v 3.3%, p=0.045) and was associated with a greater proportion of
patients who had been treated for acute rejection prior to failure (63.6% v 39.5%, p<0.001).
Mortality at 28 days post nephrectomy was 1.64%.
CONCLUSION: Nearly 40% of patients with a failed renal transplant are likely to undergo
transplant nephrectomy. Whilst up to 60% of nephrectomies occur in the first 4 weeks
following transplant failure, 40% are undertaken later, at a time when many patients have
returned to their parent haemodialysis unit. Those who underwent transplant nephrectomy
after 4 weeks from transplant failure were found to share similar baseline clinical
characteristics to those whose renal transplant was left in situ. When comparing these groups
the presence of treated acute rejection prior to failure and a diagnosis of chronic allograft
nephropathy were found to be significantly associated with proceeding to transplant
nephrectomy. No difference in overall survival between groups was found.