MANAGING A FAILED KIDNEY GRAFT. NEPHRECTOMY VERSUS EMBOLISATION

Pérez-Flores, Isabel; Sánchez-Fructuoso, Ana; Marcén, Roberto; Fernández, Ana; Fernández Lucas, Milagros; Luis Teruel, José

doi:10.3265/Nefrologia.2009.29.S.1.5639.en.full

Article information

El diagnóstico precoz de un síndrome de intolerancia o de un estado subclínico de inflamación crónica generada por un injerto no funcionante es uno de los pilares básicos que debe llevar al nefrólogo a tomar una serie de medidas encaminadas a paliar esta situación. La presencia de fiebre que no puede atribuirse a un proceso infeccioso subyacente, hematuria, dolor o aumento de tamaño del injerto son los principales criterios clínicos para el diagnóstico de un síndrome de intolerancia inmunológica al injerto. Sin embargo, en muchas ocasiones no existen manifestaciones clínicas y únicamente nos encontramos con un paciente con datos de inflamación crónica, con albúmina baja, PCR elevada y resistencia al tratamiento con agentes estimulantes de la eritropoyesis, que tras la nefrectomía o el tratamiento endovascular se normalizan. La posibilidad de mantener en el tiempo el tratamiento inmunosupresor tras la entrada en diálisis no es aconsejable, porque, aunque puede ser eficaz para evitar que el paciente desarrolle intolerancia al injerto, se paga un precio muy alto debido al incremento de las infecciones y de los eventos cardiovasculares (fuerza de recomendación A). La nefrectomía es el tratamiento de elección en el caso de la existencia de determinadas complicaciones, como la presencia de sobreinfección añadida, procesos neoplásicos o un elevado riesgo de rotura del injerto (fuerza de recomendación A). La cirugía no está exenta de riesgos y se asocia a una considerable tasa de complicaciones, con la consiguiente prolongación de la estancia hospitalaria, por lo que recurrir a procedimientos menos invasivos, como la embolización, puede ser el primer escalón siempre que no existan contraindicaciones, enumeradas en el punto 3 (fuerza de recomendación B). Es recomendable realizar profilaxis con antibioterapia antes del tratamiento endovascular, para evitar complicaciones infecciosas tras la misma (fuerza de recomendación B).

The early diagnosis of the graft intolerance syndrome or a subclinical state of chronic inflammation due to a failed kidney allograft, is one of the goals that the nephrologists must fulfill to take a series of measures directed to solve this situation. Fever, haematuria, local pain and/or tenderness are the main clinical criteria to make a diagnosis. However, oftenly there are not any clinical symptoms and only the presence of parameters of chronic inflammation (elevated C-reactive protein, erythrocyte sedimentation rate, hypoalbuminemia and anemia resistant to erythropoietin therapy) are signs of this entity. Maintenance of immunosuppressive treatment is not advisable due to the risk of infections as well as the increase in cardiovascular risk (level evidence A). Transplantectomy is the best treatment if there are some associated complications such as allograft infection, neoplasia or high risk of graft rupture. However, surgical treatment is not exempt from risks and it is associated to a considerable rate of complications, with the consequent prolongation of the hospitalization stay. Therefore it is desirable to use less invasive procedures, such as embolization. This could be the first step unless the conditions enumerated in point 3 come up (Level evidence B). It is desirable to use prophylactic antibiotic before the embolization to avoid infectious complications (Level evidence B).

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[2]

Excerpts from the United Status renal data base. 2006 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Transplantation. Am J Kidney Dis 2007;49(S1):S147-58.

[3]

Ceballos M, López-Revuelta K, Caracho R, et al. Dialysis and transplant patients Registry of the Spanish Society of Nephrology. Nefrología 2005;25(2):126-9.

[4]

López-Gómez JM, Pérez-Flores I, Jofre R, et al. Presence of a failed kidney transplant in patients who are on hemodialysis is associated with chronic inflammatory state and erythropoietin resistance. J Am Soc Nephrol 2004;15:2494-501. [Pubmed]

[5]

Rao PS, Schaubel DE, Saran R. Impact of graft failure on patient survival on dialysis: A comparison of transplant naïve and post-graft failure mortality rates. Nephrol Dial Transplant 2005;20:387-91. [Pubmed]

[6]

Kaplan B, Meier-Kriesche H-U. Death after graft loss: an important late study endpoint in kidney transplantation. Am J Transplant 2002;2:970-4. [Pubmed]

[7]

Gill JS, Pereira BJG. Death in the first year after kidney transplantation: Implications for patients on the transplant waiting list. Transplantation 2003;75:113-7. [Pubmed]

[8]

Rao PS, Schaubel DE, Jia X, et al. Survival on dialysis postkidney transplant failure: Results from the scientific registry of transplant recipients. Am J Kidney Dis 2007;49:294-300. [Pubmed]

[9]

Verresen L, Vanrenterghem Y, Waer M, Hauglustaine D, Michielsen P. Corticosteroid withdrawal syndrome in dialysis patients. Nephrol Dial Transplant 1988;3:476-7. [Pubmed]

[10]

Delgado P, Díaz F, González A, et al. Intolerance syndrome in failed renal allografts: incidents and efficacy of percutaneous embolization. Am J Kidney Dis 2005; 46:339-44. [Pubmed]

[11]

10.Madore F, Hebert MJ, Leblanc M, et al. Determinants of late allograft nephrectomy. Clin Nephrol 1995;44(5):284-9.

[12]

Almond MK, Tailor D, Marsh FP, et al. Increased erythropoietin requirements in patients with failed renal transplants returning to a dialysis programme. Nephrol Dial Transplant 1994;9:270-3. [Pubmed]

[13]

Ridker PM, Cushman M, Stampfer MJ, et al. Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med 1997;336:973-8.

[14]

Arici M, Walls J. End-stage renal disease, atherosclerosis and cardiovascular mortality: Is C-reactive protein the missing link? Kidney Int 2001;59:407-14. [Pubmed]

[15]

Stenvinkel P, Heimburger O, Paultre F, et al. Strong association between malnutrition, inflammation and atherosclerosis in chronic renal failure. Kidney Int 1999;55:1899-911. [Pubmed]

[16]

Gill JS, Abichandani R, Kausz AT, Pereira BJ. Mortality after kidney transplant failure: The impact of non-immunologic factors. Kidney Int 2002;62:1875-83. [Pubmed]

[17]

Gallo CD, Grinyo JM, Seron D, et al. Routine allograft nephrectomy in late renal failure. Transplantation 1990;44:1204-6.

[18]

Kiberd BA, Belitsky P. The fate of the failed renal transplant. Transplantation 1995;59:645-7. [Pubmed]

[19]

Smak Gregoor PJ, Zietse R, van Saase JL, et al. Immunosuppression should be stopped in patients with renal allograft failure. Clin Transplant 001;15:397-401.

[20]

Johnston O, Rose C, Landsberg D, Gourlay WA, Gill JS. Nephrectomy after transplant failure: current practice and outcomes. Am J Transplant 2007;7:961-7.

[21]

Secin FP, Rovegno AR, Brunet MR, Marrugat REJ, Michel MD, Fernández H. Cumulative incidence, indications, morbidity and mortality of transplant nephrectomy and the most appropriate time for graft removal: only nonfunctioning transplants that cause intractable complications should be excised. J Urol 2003;168:1242-6.

[22]

Hansen BL, Rohr N, Svendsen V, Birkeland SA. Graft failure and graft nephrectomy without severe complications. Nephrol Dial Transplant 1987;2:189-90. [Pubmed]

[23]

Chiverton SG, Murie JA, Allen RD, Morris PJ. Renal transplant nephrectomy. Surg Gynecol Obstet 1987;164:324-8. [Pubmed]

[24]

Rodríguez García J, García Buitron J, Chantada Abal V, et al. Trasplantectomía renal. Actas Urol Esp 1992;16:25-8.

[25]

Rosenthal JT, Peaster ML, Laub D. The challenge of kidney transplant nephrectomy. J Urol 1993;149:1395-7. [Pubmed]

[26]

Riera Canals L, Franco Miranda E, López Costea MA, et al. La trasplantectomía hoy indicaciones y complicaciones. Actas Urol Esp 1993;17:492-6. [Pubmed]

[27]

Fernández Aparicio T, Miñana López B, Fraile Gómez B, et al. trasplantectomía renal. Arch Esp Urol 1996;49:1079-91. [Pubmed]

[28]

Burgos Revilla FJ, Orofino Azcue L, del Hoyo Campos J, et al. trasplantectomía del injerto renal. Arch Esp Urol 1994;47:255-61.

[29]

O'Sullivan DC, Murphy DM, McLean P, Donovan MG. Transplant nephrectomy over 20 years: factors involved in associated morbidity and mortality. J Urol 1994;151:855-8. [Pubmed]

[30]

29.Mora Durbán M, Cárcamo Valor P, Navarro Sebastían J, et al. Injerto renal funcionante: indicaciones de trasplantectomía. Arch Esp Urol 1989;42:873-8. [Pubmed]

[31]

30.Marcen R, Teruel JL. Patient outcomes after kidney allograft loss. Transplant Reviews 2008;22:62-72.

[32]

Toledo-Pereyra LH, Gordon C, Kaufmann R, Whitten JI, Mittal VK. Role of immediate versus delayed nephrectomy for failed renal transplants. Am Surg 1987;53:534-6. [Pubmed]

[33]

Vanrenterghem Y, Khamis S. The management of the failed renal allograft. Nephrol Dial Transplant 1996;11:955-7. [Pubmed]

[34]

Glicklich D, Greenstein SM, Posner L, Schechner RS, Tellis VA. Transplant nephrectomy in the cyclosporine era. J Am Soc Nephol 1993;4:937-9.

[35]

Adhikary SD, Viswaroop SB, Kekre NS, et al. Comparative study of graft nephrectomy in pre-cyclosporine and cyclosporine era. Urol Int 2008;80:80-3. [Pubmed]

[36]

Sumrani N, Delaney V, Hong JH, Daskalakis P, Sommer BG. The influence of nephrectomy of the primary allograft on retransplant graft outcome in the cyclosporine era. Transplantation 1992;63:52-5.

[37]

Lorenzo V, Díaz F, Pérez L, Domínguez ML, et al. Ablation of irreversibly rejected renal allograft by embolization with absolute ethanol: a new clinical application. Am J Kidney Dis 1993;22:592-5. [Pubmed]

[38]

González-Satué C, Riera L, Franco E, et al. Percutaneous embolization of the failed renal allograft in patients with graft intolerance syndrome. BJU Int 2000;86:610-2. [Pubmed]

[39]

Atar E, Belenky A, Neuman-Levin M, Yussim A, Bar-Nattan N, Bachar GN. Nonfunctioning renal allograft embolization as an alternative to graft nephrectomy: report on seven years' experience. Cardiovasc Intervent Radiol 2003;26:37-9. [Pubmed]

[40]

Cofan F, Real MI, Vilardell J, et al. Percutaneous renal artery embolization of non-functioning renal allografts with clinical intolerance. Transpl Int 2002;15:149-55. [Pubmed]

[41]

Pérez Martínez J, Gallego E, Juliá E, et al. Embolization of non-functioning renal allograft: efficacy and control of systemic inflammation. Nefrología 2005;25(4):422-7. [Pubmed]

[42]

41.Wéclawiack H, Kamar N, Mehrenberger M, et al. Alphainterferon therapy for chronic hepatitis C may induce acute allograft rejection in kidney transplant patients with failed allograft. Nephrol Dial Transplant 2008;23(3):1043-7. [Pubmed]

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