Introduction:
As the number of renal transplants is increasing throughout the world there is also increase in number of patients developing graft failure. These patients eventually return to dialysis and at are risk of graft intolerance syndrome and infections. Graft nephrectomy is being performed in patients with early graft failure (<1 year after transplant) due to vascular thrombosis, acute rejection, graft intolerance or in late graft failure (>1 year after transplant) due to chronic graft dysfunction or to prevent chronic inflammatory state. There is paucity of literature on indications, histopathology and outcomes of patients undergoing allograft nephrectomy.
Methods:
Retrospective analysis from January 2013 to December 2023 revealed 59 patients with graft nephrectomy at our institution. Clinical, demographic, operative details, biochemical parameters and follow up were obtained from hospital records. Histopathology of the graft nephrectomy specimens were retrospectively analysed and evaluated with C4d in accordance with 2022 Banff update. Chi-square test was used to compare categorical variables and student t-test was used to compare continuous variables. A p value of <0.05 was considered to be statistically significant.
Results:
Mean age of the patients was 40 years (range 24-78 years). There were 51 males and 8 females. There was 1 case of cadaveric transplant and remaining 58 cases were of live renal transplants. 12 (20%) of the patients were ABO incompatible grafts. There was significant association between ABO incompatible graft with subsequent early graft nephrectomy (11 cases) as compared to late allograft nephrectomy (1 case) with P value=0.018. All the patients were on triple drug immunosuppression. Mean serum baseline creatinine following transplantation was 1.18 mg/dl (range 0.7 to 1.8 mg/dl). Early graft nephrectomy was performed in 35 patients and late graft nephrectomy was performed in 24 patients. The indication for early graft nephrectomy included hyperacute rejection, vascular thrombosis, acute rejection non- responsive to immunosuppression, graft intolerance syndrome and infections. Indications for late graft nephrectomy group included chronic graft dysfunction and histopathology showed chronic antibody mediated rejection, chronic pyelonephritis, chronic T cell mediated rejection, transplant glomerulopathy with moderate IF/TA and a case each of clear cell renal cell carcinoma and mucormycosis.
In 30 patients a renal graft biopsy had been performed prior to graft nephrectomy. In 16 of these patients, there was evidence of antibody mediated rejection), 14 of these patients underwent early graft nephrectomy and only 2 patients underwent late allograft nephrectomy indicating significant association between antibody mediated rejection and subsequent early graft nephrectomy (p=0.008). Remaining biopsies results included borderline acute cellular rejection, diffuse acute cortical necrosis, acute tubular injury, acute CNI toxicity and acute graft pyelonephritis.
On follow up, mortality was seen in 29% (17 of the 59 with graft nephrectomy) patients. All the 17 deaths were seen in early graft nephrectomy group and occurred within 1 year of performing graft nephrectomy with complications arising from septicaemia or due to cardiovascular events. Of these 10 deaths occurred within 1 month of performing graft nephrectomy.
Conclusions:
Allograft nephrectomy is uncommon procedure the indications for which are not standardized. Vascular thrombosis, acute rejection non-responsive to treatment and graft intolerance form common indications in early graft nephrectomy and chronic graft dysfunction in late nephrectomy group. Histopathology can highlight actual cause of graft loss and may benefit in management post nephrectomy. It has high mortality and morbidity so institutes should weigh benefits versus risk before planning the procedure.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.