Effect of Maintaining Immunosuppression After Kidney Allograft Failure on Mortality and Retransplantation

Suryanarayanan Balakrishnan; Byron Smith; Andrew Bentall; Aleksandra Kukla; Massini Merzkani; Mark Stegall; Carrie Schinstock

doi:10.1097/TXD.0000000000001415

Effect of Maintaining Immunosuppression After Kidney Allograft Failure on Mortality and Retransplantation

Transplant Direct. 2022 Dec 7;9(1):e1415. doi: 10.1097/TXD.0000000000001415. eCollection 2023 Jan.

Authors

Suryanarayanan Balakrishnan¹, Byron Smith², Andrew Bentall³, Aleksandra Kukla³, Massini Merzkani⁴, Mark Stegall³, Carrie Schinstock³

Affiliations

¹ Department of Internal Medicine, St. Vincent's Hospital, Worcester, MA.
² Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN.
³ William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN.
⁴ Division of Nephrology, Washington University, St. Louis, MO.

Abstract

Few studies have addressed immunosuppression management after allograft failure (AF). Immunosuppression withdrawal to minimize complications must be balanced with the risk of sensitization and potentially reduced retransplantation. We aimed to determine relationships between immunosuppression, death, sensitization, and retransplantation among patients with AF.

Methods: We performed a single-center retrospective study of patients transplanted from October 2007 to May 2017 with AF. We collected data on demographics, immunosuppression, calculated panel reactive antibody (cPRA) levels, death, retransplantation, and dialysis. Cox regression models were used to evaluate factors associated with death and retransplantation.

Results: From October 2007 to May 2017, 1354 solitary ABO-compatible transplants were performed, of which 97 failed. Ten percent of patients received a preemptive retransplant. Among those who returned to dialysis (n = 87), 35% died, 25% received another transplant, and 30% remained on dialysis. After AF, 46% of patients discontinued immunosuppression. The cPRA was unchanged if immunosuppression was maintained, but immunosuppression discontinuation was associated with increased cPRA from a median (interquartile range) of 18 (0-99) to 96 (88.5-100.0; P = 0.003). Age at failure (hazard ratio, 1.1; confidence interval, 1.0-1.1) and cardiovascular disease were associated with death (hazard ratio, 2.9; confidence interval, 1.2-7.0) in multivariate analysis. Importantly, immunosuppression maintenance was not associated with increased death or retransplantation despite the increase in cPRA that occurred when immunosuppression was discontinued.

Conclusions: Kidney transplant recipients with AF have a high mortality rate after dialysis initiation. Although immunosuppression withdrawal was associated with increased cPRA, it was not associated with reduced retransplantation. Therefore, it is reasonable to discontinue immunosuppression after AF despite sensitization if retransplantation is delayed.