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Kidney retransplantation in children following rejection and recurrent disease

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Abstract

Retransplantation accounts for approximately 15 % of the annual transplants performed in the USA, and in the recent International Collaborative Transplant Study report on pediatric patients 15.2 % of the 9209 patients included in the report were retransplant recipients. Although the significant advances in clinical management and newer immunosuppressive agents have had a significant impact on improving short-term allograft function, it is apparent that long-term allograft function remains suboptimal. Therefore, it is likely that the majority of pediatric renal allograft recipients will require one or more retransplants during their lifetime. Unfortunately, a second or subsequent graft in pediatric recipients has inferior long-term graft survival rates compared to initial grafts, with decreasing rates with each subsequent graft. Multiple issues influence the outcome of retransplantation, with the most significant being the cause of the prior transplant failure. Non-adherence-associated graft loss poses unresolved ethical issues that may impact access to retransplantation. Graft nephrectomy prior to retransplantation may benefit selected patients, but the impact of an in situ failed graft on the development of panel-reactive antibodies remains to be definitively determined. It is important that these and other factors discussed in this review be taken into consideration during the counseling of families on the optimal approach for their child who requires a retransplant.

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Author information

Authors and Affiliations

  1. Pediatric Residency Program, Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, USA

    Rebecca C. Graves

  2. Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, NY, USA

    Richard N. Fine

  3. Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA

    Richard N. Fine

Authors
  1. Rebecca C. Graves
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  2. Richard N. Fine
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Correspondence to Rebecca C. Graves.

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The authors declare no conflict of interest.

Additional information

Answers

1: c; 2: b; 3: b; 4: d; 5: d

Questions

Questions

  1. 1.

    Which of the following is true regarding the current state of kidney retransplantation?

    1. a.

      There are decreasing numbers of patients on the DD wait list awaiting retransplantation

    2. b.

      Graft survival rate increases with subsequent transplants

    3. c.

      Recent changes in organ allocation policy to pediatric patients have resulted in the increased use of HLA-mismatched organs

    4. d.

      Repeat transplant patients comprise approximately 25 % of the pediatric wait list

  2. 2.

    The outcome (graft survival rate) of a retransplant is:

    1. a.

      The same as an initial graft

    2. b.

      ±15 % lower than an initial graft

    3. c.

      Better if the failed graft remains in situ

    4. d.

      Not influenced by the recurrence of the primary disease

  3. 3.

    Which of the following is true?

    1. a.

      BK polyoma virus nephropathy has a high rate of recurrence, and therefore should be a contraindication to retransplantation

    2. b.

      FSGS is the most common disease that recurs in pediatric retransplant recipients.

    3. c.

      EBV-associated post-transplant lymphoproliferative disease has a high rate of recurrence in subsequent grafts

    4. d.

      The rate of recidivism in non-adherent patients is relatively high, and therefore non-adherence should be a contraindication to retransplantation

  4. 4.

    Which of the following is true of BK nephropathy and EBV PTLD following an initial graft loss?

    1. a.

      They do not recur following retransplantation

    2. b.

      They are a contraindication to retransplantation

    3. c.

      Viral prophylaxis is uniformly effective in preventing recurrence following retransplantation

    4. d.

      Recurrence is limited following retransplantation

  5. 5.

    All of the following treatments may be required to facilitate retransplantation EXCEPT:

    1. a.

      Reduction in HLA PRA

    2. b.

      Reduction in DSA

    3. c.

      Reduction in putative biomarker

    4. d.

      Enhance activation of the classical complement pathway

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Graves, R.C., Fine, R.N. Kidney retransplantation in children following rejection and recurrent disease. Pediatr Nephrol 31, 2235–2247 (2016). https://doi.org/10.1007/s00467-016-3346-0

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  • DOI: https://doi.org/10.1007/s00467-016-3346-0

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