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Retransplantation after nonadherence‐related kidney allograft failure – forgive or forget?

The decision to retransplant a patient who has lost a first renal allograft due to documented nonadherence (NA) to the medical regimen and/or their prescribed immunosuppressive drug therapy is one of the most vexing issues in the clinical practice of kidney transplantation. Very often documenting NA is challenging because circumstances and individual episodes are imprecise and involve both voluntary and involuntary behaviors. These episodes are further complicated by the commonly associated youth of these patients and a likely further need for transplantation even when adherence is observed. It is important to update the impact of NA on kidney transplant outcomes as best as possible and try to offer guidance on how to proceed when such patients are encountered. The present study from Australia offers a window into current outcomes when recipients who exhibited NA as the reason for first graft loss are retransplanted. They demonstrated that a selected group of such patients (perhaps 1/3) can have a successful outcome after retransplantation with heightened vigilance. Although further NA behavior was exhibited in many. Selecting these candidates remains more art than science, and new approaches should be shared among transplant centers worldwide.