Journal Information
Vol. 29. Issue. S1.March 2009
Pages 1-77
Vol. 29. Issue. S1.March 2009
Pages 1-77
Full text access
RETRANSPLANT
Retrasplante
Visits
4383
Roberto Marcéna, Ana Fernándeza, Milagros Fernández Lucasa, José Luis Teruela, Isabel Pérez-Floresb, Ana Sánchez-Fructuosob
a Servicio de Nefrología, Hospital Ramón y Cajal., Madrid, Madrid, España,
b Servicio de Nefrología, Hospital Clínico San Carlos, Madrid, Madrid, España,
This item has received
Article information

A pesar de los avances en el tratamiento inmunosupresor y en los cuidados del enfermo trasplantado, a los tres años del trasplante el 20-30% de los receptores habrán perdido el injerto y la pérdida continuará a razón de un 2-4% anual. Estos enfermos de nuevo se incluyen en programas de diálisis, y constituyen entre el 4 y 10% de los enfermos admitidos anualmente para tratamiento dialítico. De ellos, el 40-60% según las series se incluyen en lista de espera para un segundo trasplante, lo que origina un aumento del número de enfermos en espera de trasplante y plantea el dilema sobre los derechos a trasplantarse en los programas basados en donantes cadáver. Como característica importante, los enfermos en espera de un segundo o tercer trasplante con frecuencia tienen anticuerpos circulantes frente a los antígenos HLA. El retrasplante constituye la mejor forma de tratamiento de la insuficiencia renal crónica (IRC), y los resultados de la supervivencia del injerto se acercan a los del primer trasplante, a pesar de ser considerados enfermos de alto riesgo. También mejora la supervivencia del enfermo respecto a aquel que permanece en lista de espera. Los grupos más favorecidos por el retrasplante son los enfermos en que la diabetes tipo I fue la causa del fallo renal y el grupo de edad entre 18 y 50 años (evidencia C). A pesar de las ventajas terapéuticas del retrasplante, el porcentaje de enfermos que se somete a un segundo trasplante permanece estacionario, posiblemente por la aplicación de criterios más amplios en cuanto a la aceptación de candidatos a trasplantarse (evidencia B). En el segundo trasplante, se pueden repetir los antígenos HLA-AB no compartidos si el receptor no ha desarrollado anticuerpos específicos. La prueba cruzada reciente e histórica debe ser negativa. Las pautas de inmunosupresión a utilizar son las mismas que en el primer trasplante. Complicaciones asociadas a la inmunosupresión, como la enfermedad linfoproliferativa y la nefropatía por el virus BK, así como las glomerulopatías recidivantes, no son contraindicaciones para el retrasplante (evidencia C).

Despite the advances in immunosuppressive therapy and in patient care, about 20-30% of patients wi l l have lost their grafts after 3 years and this loss will continue by 3-4% per year. These patients are included in maintenance dialysis programmes and account for 4 to 10% of those admitted every year for maintenance dialysis therapy. Among those patients who loss their grafts 40-60% are included in transplant waiting l ists. This increases the number of patients waiting for a graft and raises the di lemma about the rights to be included in deceased donor programmes. A common characteristic of these patients waiting for a second or even third transplant is the presence in the blood of antibodies to HLA antigens. A new transplant is the best therapeutic option for these patients, and the results are quite close to those achieved for the first graft. Moreover, a new transplant improves patient outcome when compared with those remaining in the waiting l ist. The best results are obtained in diabetic patients and in those between 18 to 50 years old (Evidence C). However, the percentage of patients retransplanted has not varied in the last years, possibly due to the wider criteria adopted on candidate selection that increases the waiting l ists (Evidence B). In the second transplant, mismatched HLA-A,B antigens could be repeated if the recipient has not developed specific antibodies to these antigens. Recent cross-match has to be negative. Immunosuppressive therapy is simi lar to that used with first transplants. Lymphoprol iferative diseases, BK virus nephropathy and primary glomerulonephritis do not preclude a second transplant (Evidence C).

Bibliography
[1]
Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 2007;341:1725-30. [Pubmed]
[2]
McDonald SP, Russ GR. Survival of cadaveric kidney transplants compared with those receiving dialysis treatment in Australia and New Zealand 1991-2001. Nephrol Dial Transplant 2002;17:2212-9. [Pubmed]
[3]
Ojo AO, Wolfe RA, Agodoa LY, et al. Prognosis alter primary renal transplant failure and the beneficial effect of repeat transplantation. Transplantation 1998;66:16519.
[4]
Rao PS, Schaubel DE, Wei G, Fenton SSA. Evaluating the survival benefit of kidney retransplantation. Transplantation 2006;82:669-74. [Pubmed]
[5]
Berthoux F, Jones E, Gellert R, Mendel S, Saker L, Briggs D. Epidemiological data of treated end-stage renal failure in the European Union (EU) during the year 1995: report of the European Renal Association Registry and the National Registries. Nephrol Dial Transplant 1999;14:2332-42. [Pubmed]
[6]
Excerpts from the United States renal data base. 2006 annual data report: atlas of chronic kidney disease & end-stage renal disease in the United States. 7 Transplantation Am J Kidney Dis 2007;49(1):S147-58.
[7]
Denny RR, Sumrani N, Miles AMV, et al. Survival on hemodialysis versus renal transplantation following primary renal allograft failure. Transplant Proc 1997;29:3602-4. [Pubmed]
[8]
Gallichio MH, Hudson S, Young CJ, Diethelm AG, Deierhoi MH. Renal retransplantation at the University of Alabama at Birmingham: incidence and outcome. En: Cecka JM, Terasaki PI, eds. Los Angeles, CA: UCLA Tissue typing laboratory. Clinical transplants 1998;14:169-75.
[9]
Howard RJ, Reed AI, van der Werf WJ, Hemming AW, Patton PR, Scornik JC. What happens to renal transplant recipients who lose their graft? Am J Kidney Dis 200138:31-5.
[10]
10.Marcén R, Pascual J, Tato AM, et al. Renal transplant recipients outcome after losing the first graft. Transplant Proc 2003;35:1679-81. [Pubmed]
[11]
Rigden S, Mehls O, Gellert R, on behalf of the scientific advisory board of the ERA-EDTA registry. Factors influencing second renal allograft survival. Scientific Advisory Board of the ERA-EDTA Registry. European Renal Association-European Dialysis and Transplant Association. Nephrol Dial Transplant 1999;14:566-9.
[12]
Coupel S, Giral-Clase M, Karam G, et al. Ten-year survival of second kidney transplants: impact of immunologic factors and renal function at 12 months. Kidney Intern 2003;64:674-80.
[13]
13.Magee JC, Barr ML, Basadona GP, et al. Repeat organ transplantation in the United States, 1996-2005. Am J Transplant 2007;7:1424-33.
[14]
Gill JS, Abichandani R, Khan S, Kausz AT, Pereira BJG. Opportunities to improve the care of patients with kidney transplant failure. Kidney Int 2002;61:2193-200. [Pubmed]
[15]
Arias M, Escallada R, Martín de Francisco MA, et al. Return to dialysis after renal transplantation. Which would be the best way? Kidney Int 2002;61(80):S85-8.
[16]
Hirata M, Terasaki PI. Renal retransplantation. En: Cecka JM, Terasaki PI, eds. Los Angeles, CA: UCLA Tissue typing laboratory. Clinical Transplants 1994;34:419-33.
[17]
Jordan SC, Pescovitz MD. Presensitization: the problem and its management. Clin J Am Soc Nephrol 2006;1:421-32. [Pubmed]
[18]
Kriaa F, Laurian Y, Hiesse C, Tchernia G, Charpentier B. Five years¿ experience at one centre with protein A immunoadsorption in patients with deleterous allo/auttoantibodies (anti-HLA antibodies, autoimmune bleeding disorders) and postransplant patients relapsing with focal glomerular sclerosis. Nephrol Dial Transplant 1995;10(6):108-10. [Pubmed]
[19]
19.Montgomery RA, Zachary AA, Racusen LC, et al. Plasmapheresis and intravenous immune globulin provides effective rescue therapy for refractory humoral rejection and allows kidneys to be successfully transplanted into crossmatch-positive recipients. Transplantation 2000;70:887-95. [Pubmed]
[20]
Cho YW, Cecka JM. Crossmath test-An analysis of UNOS data from 1991-2000. En: Cecka JM, Terasaki PI, eds. Los Angeles, CA: UCLA Tissue typing laboratory. Clinical Transplants 2001;22:237-46.
[21]
Bryan CF, Baier KA, Nelson PW, et al. Long-term graft survival is improved in cadaveric renal retransplantation by flow cytometric crossmatching. Transplantation 1998;66:1827-32. [Pubmed]
[22]
Fernández-Juárez G, Pascual J, Marcén R, et al. Retrasplante renal en enfermos tratados con ciclosporina. Nefrología 1999;29:262-7.
[23]
Sellers MT, Velidedeoglu E, Bloom ED, et al. Expanded ¿criteria donor kidneys: a single-center clinical and short-term financial analysis-cause for concern in retransplantation. Transplantation 2004;78:1670-5. [Pubmed]
[24]
Almond PS, Matas AJ, Gillingham K, et al. Risk factors for second renal allografts immunosuppressed with cyclosporine. Transplantation 1991; 52:253-258. [Pubmed]
[25]
Abouljoud MS, Deierhoi MH, Hudson SL, Diethelm AG. Risk factors affecting second renal transplant outcome, with special reference to primary allograft nephrectomy. Transplantation 1995;60:138-44. [Pubmed]
[26]
Gjertson DW. A multi-factor analysis of kidney regraft outcomes. En: Cecka JM, Terasaki PI, eds. Los Angeles, CA: UCLA Tissue typing laboratory. Clinical transplants 2002;28:335-49.
[27]
Lair D, Coupel S, Giral M, et al. The effect of a first kidney transplant on a subsequent transplant outcome : an experimental and clinical study. Kidney Int 2005;67:2368-75. [Pubmed]
[28]
Johnston O, Rose C, Landsberg D, Gourlay WA, Gill JS. Nephrectomy after transplant failure: current practice and outcomes. Am J Transplant 2007;7:1961-7. [Pubmed]
[29]
Khakhar AK, Shahinian VB, House AA, et al. The impact of allograft nephrectomy on percent panel reactive antibody and clinical outcome. Transplant Proc 2003;862-3.
[30]
López-Gómez JM, Pérez-Floes I, Jofré R, et al. Presence of a failed kidney transplant in patients who are on hemodialysis is associated with chronic inflammatory state and erytropoietin resistance. J Am Soc Nephrol 2004;15:2494-501. [Pubmed]
[31]
Christiaans MHL, Overhof R, ten Haafy A, Nieman F, van Hoof JP van den Berg-Loonen EM. No advantage of flow cytomatry crossmatch over complement-dependent cytotoxicity in immunologicaly well-documented renal allograft recipients. Transplantation 1996;62:1341-7. [Pubmed]
[32]
Cecka JM, Terasaki PI. Repeating HLA antigen mismatches in renal retransplants -a second class mistake. Transplantation 1994;57:515-9. [Pubmed]
[33]
33.Miles CD, Schaubel DE, Jia X, Ojo AO, Port FK, Rao PS. Mortality experience in recipients undergoing repeat transplantation with expanded criteria donor and non-ECD deceased-donor kidneys. Ame J Transplant 2007;7:1140-7.
[34]
Briganti EM, Epi MC, Russ GR, McNeil JJ, Tkins RC, Chadban SJ. Risk of renal allograft loss from recurrent glomerulonephritis. N Eng J Med 2002;347:103-9.
[35]
Pardon A, Audard V, Caillard, et al. Risk factors and outcome of focal and segmental glomerulonephritis recurrence in adult renal transplant recipients. Nephrol Dial Transplant 2006;21:1053-9. [Pubmed]
[36]
European best practice guidelines for renal transplantation (part 2). Late recurrence of primary glomerulonephritides. Nephrol Dial Transplant 2002;17:16-9. [Pubmed]
[37]
Hickey D, Nalesnik M, Vivas C, et al. Renal retransplantation in patients who lost their allografts during management of previous post-transplant lymphoproliferative disease. Clin Transplant 1990;4:187-90.
[38]
Demircin G, Rees L. Retransplantation after post-transplant lymphoproliferative disease. Pediatr Nephrol 1997;11:358-60. [Pubmed]
[39]
Birkeland SA, Hamilton-Dutoit S, Bendtzen K. Long-term follow-up of kidney transplant patients with posttransplant lymphoproliferative disorders: duration of posttransplant lymphoproliferative disorder-induced operational graft tolerance interleukin-18 course, and results of retransplantation. Transplantation 2003;76:153-8. [Pubmed]
[40]
Karras A, Thervet E, Le Meur J, Baudet-Bonneville V, Kessler M, Legendre C. Successful, renal retransplantation after post-transplant lymphoproliferative disease. Am J Transplant 2004;4:1904-9. [Pubmed]
[41]
Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal transplant recipients. N Eng J Med 2002;347:488-96.
[42]
Poduval RD, Meehan SM, Woodle ES, et al. Successful retransplantation after renal allograft loss to polyoma virus interstitial nephritis. Transplantation 2002;73:1166-9. [Pubmed]
[43]
Ramos E, Vincenti F, Lu WX, et al. Retransplantation in patients with graft loss caused by polyoma virus nephropathy. Transplantation 2004;77:131-3. [Pubmed]
[44]
44.Womer KL, Meier-Kriesche H-U, Patton PR, et al. Preemptive retransplantation for BK virus nephropathy: successful outcome despite active viremia. Am J Transplant 2006;6:209-13. [Pubmed]
Idiomas
Nefrología (English Edition)
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?