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Editorial Comment from Dr Tillou to Impact of graft nephrectomy on outcomes of second kidney transplantation

This article addresses an important and current subject in the field of renal transplantation. To retain a previous allograft before a second transplantation remains controversial despite several previous studies. Studies in the literature did not show that the nephrectomy of a failed allograft significantly influences the survival of a subsequent graft. In recent studies, Schleicher et al. observed a negative influence of primary allograft nephrectomy on the second transplant outcome. They further found that a lower donor age and delayed retransplantation after nephrectomy might improve results. Sumrani et al. also reported that primary allograft nephrectomy, by increasing PRA levels, could be detrimental to the new transplant. In contrast, an analysis of 127 retransplant patients by Douzdjian et al. found that despite the association of primary allograft nephrectomy with higher preformed antibody levels, regraft survival was not influenced by nephrectomy. In the present study, as in those of many other teams, the authors chose to remove the first renal transplant because of a graft intolerance syndrome or an acute rejection. Fadli et al. concluded that transplant nephrectomy is not a risk factor of increased retransplant failure. They confirmed the conclusions of the most recent studies dealing with the same subject. The decision to remove or retain a failed graft in the context of retransplantation should be based on known clinical indications for the procedure. However, the authors did not take into account other characteristics of the recipients waiting for a second transplantation. The decision to remove or retain a failed graft should also be based on an expected time to retransplantation, depending on the recipient’s blood type and level of sensitization. Chronic inflammation decreases hemoglobin levels, and blood transfusion must be avoided before transplantation. To leave a previous graft in patients with a potentially long duration of dialysis could compromise a second transplantation. Chronic inflammation related to the retained allograft could also lead to severe denutrition, which has a negative impact on any surgical procedure, such as renal transplantation. Allograft nephrectomy should not be restricted to patients with graft-related symptoms, but should be discussed while taking into account recipient age, expected time on the waiting list and the biological impact of the retained graft.