- Email: [email protected]
Graft Survival in Patients Who Received Second Allograft, Comparing Those With or Without Previous Failed Allograft Nephrectomy
Graft Survival in Patients Who Received Second Allograft, Comparing Those With or Without Previous Failed Allograft Nephrectomy Á. Sánchez-González*, J. Carrasco-Valiente, A.J. Arenas-Bonilla, J.P. Campos-Hernández, A. Blanca-Pedregosa, J.M. Ruíz-García, J. Valero-Rosa, E. Gómez-Gómez, J.J. Salamanca-Bustos, D. Navarro-Cabello, and M.J. Requena-Tapia Department of Urology, Hospital Universitario Reina SofíaeIMIBIC, Córdoba, Spain
ABSTRACT Introduction. Nowadays, the number of patients receiving a second graft is growing, and the management of failed grafts is still controversial. Objective. Our objective was to analyze the influence of graft nephrectomy on graft and patient survival. Materials and Methods. We retrospectively evaluated the demographic features and graft outcomes of 63 recipients who received second allografts between August 1985 and April 2013. They were divided into two groups: group A, those who underwent nephrectomy of failed graft (n ¼ 21, 33.3%), and group B, those whose failed graft was retained (n ¼ 42, 66.6%). c2 and Mann-Whitney U tests were used to compare demographic characteristics and graft features in both groups. Kaplan-Meier test was used to analyze graft and patient survival. Finally, univariate and multivariate analysis was done using Cox regression. Results. Demographic characteristics of donor and receptors were similar in both groups. Overall panel-reactive antibody (P ¼ .040) showed statistically significant differences between groups (72.0 25.3 in group A and 54.8 30.0 in group B). Hemodialysis duration was longer in group A (P ¼ .023, 112.2 72.8 vs 70.9 66.9 months). The percentage of patients who had delayed graft function was higher in group A (58.8% vs 27.3%, P ¼ .029). Kaplan-Meier test found no differences between groups (P ¼ .344); group A, 107.4 months (95% confidence interval [CI] 74.0 to 140.8) and group B, 82.7 months (95% CI 62.5 to 102.8). We found no differences in terms of patient survival (P ¼ .798) with the Kaplan-Meier test. In group A, patient survival was 164.5 months (CI 137.7 to 191.31) and in group B, 152.0 months (95% CI 125.5 to 178.5). Conclusions. Failed graft nephrectomy did not show a negative impact on graft and patient survival.
A
LTHOUGH several advances have been made in kidney transplantation outcomes, graft failure still affects up to 10% of renal transplants [1]. In those cases, repeat transplantation improves overall patient survival [2]; however, outcomes of second grafts still lag behind of those of primary grafts [3]. Several studies have investigated the effect of failed graft nephrectomy on retransplantation outcome [4e9], but the management of asymptomatic failed allograft remains controversial. ª 2016 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 48, 2895e2898 (2016)
The aim of our study was to analyze the impact of failed graft nephrectomy on a subsequent transplantation, by comparing graft and patient survivals of those patients with transplantectomy prior to second transplantation against those without transplantectomy.
*Address correspondence to Álvaro Sánchez-González, Hospital Universitario Reina SofíaeIMIBIC, Avenida Menéndez Pidal s/n, 14004 Córdoba, Spain. E-mail: [email protected] 0041-1345/16 http://dx.doi.org/10.1016/j.transproceed.2016.09.016
2895
2896
SÁNCHEZ-GONZÁLEZ, CARRASCO-VALIENTE, ARENAS-BONILLA ET AL
MATERIALS AND METHODS Between August 1985 and April 2013, 1073 kidney transplantations were performed in our center, including 155 (14.45%) retransplantations. Of the 134 patients who were retransplanted, 42 (3.91%) patients retained the failed graft in situ (group A). We used Microsoft Office Excel 2007 (Redmond, Wash, United States) to generate a list of random values without repetition to perform a simple randomization for group A. All patients (n ¼ 21, 1.96%) who received second allograft and underwent failed graft nephrectomy were selected (group B). Donor and graft data and surgical and follow-up information were collected retrospectively from the local transplantation registry and patients’ medical history files. Primary endpoint was the influence of graft nephrectomy on patient and graft survival. Demographic characteristics, perioperative characteristics, panel-reactive antibody (PRA) levels, delayed graft function, HLA matching, rate of acute rejections, and renal function were also examined. Immunosuppressive therapy is as follows: CellCept (Genentech, San Francisco, Calif, United States) 500 mg every 12 hours; Advagraf 0.2 mg/kg/d; prednisone daily doses between 5 and 20 mg. If there is any intolerance of these drugs, the dosage can be modified. For hyperimmunized patients, donor or receptor or receptor asystole expanded donor criteria, and thymoglobulin induction is performed at 1 mg/kg/dose, 5 doses, beginning pretransplant. Delayed graft function was defined as the postoperative need for dialysis in the first post-transplant week. Glomerular filtration rate was estimated using the abbreviated Modification of Diet in Renal Disease equation. Patient characteristics are presented using mean and standard deviation for continuous variables, and frequencies and proportions for categorical variables. Groups were compared using Mann-Whitney U test for continuous variables and c2 test for categorical ones. Univariate and multivariate Cox regression test was performed. We analyzed the association between transplantectomy and graft and patient survival with the Kaplan-Meier test. All statistical analyses were carried out using SPSS v15.0 (IBM, Amonk, New York, United States) software package. All tests were 2-sided, and P values < .05 were accepted as significant.
RESULTS
Indications for allograft nephrectomy were recurrent urinary tract infections, hematuria, pain, adverse effects of immunosuppressive drugs, tumors, or need to create room for the new graft. The most common cause of end-stage renal failure was glomerulonephritis (n ¼ 21, 33.3%), followed by unknown etiology (n ¼ 16, 25.4%) and vesicoureteral reflux disease (n ¼ 5, 7.4%). We also included patients with diabetic nephropathy and polycystic kidney disease (n ¼ 3, 4.8% in both cases) and malignant hypertension (n ¼ 2, 3.2%) and Alport disease (n ¼ 1, 1.6%) disease. No differences were found when we compared demographic characteristics (Table 1). When retransplantation characteristics were compared, significant differences were found at overall PRA levels, which were higher in the transplantectomy group
(72.0% 25.3% vs 54.8% 30.4%; P ¼ .04). We also found a significantly longer duration of hemodialysis in group B (112.2 72.8 vs 70.9 66.9 months; P ¼ .023). No other differences were found (Table 1). We found statistically significant differences in patient survival, which was longer in the transplantectomy group (125.0 55.4 vs 85.0 61.0 months, P ¼ .015). We also found a higher proportion of patient with delayed graft function in group B (58.8% vs 27.3%, P ¼ .0291). As shown in Table 1, no other differences were found on graft outcome. No statistical association was found with Cox regression multivariate test between the variables used and graft survival. When we analyzed the effect of nephrectomy on patient or graft overall survival by Kaplan-Meier survival test, no association was found (P ¼ .798 and P ¼ .334, respectively, Fig 1). DISCUSSION
Kidney retransplantation improves quality of life and is more cost-effective than hemodialysis and peritoneal dialysis [10]. There is a lack of consensus about the optimal management of the failed renal allograft in patients awaiting retransplantation. Even without any clinical symptoms, retained failed allograft induces chronic inflammatory response syndrome and is associated with higher morbidity on hemodialysis [11]. But, in contrast, perioperative morbidity of graft nephrectomy is considered high (<10%) and mortality is reported between 0.7% and 5% [12]. Ahmad et al [4] showed that PRA level is increased in patients with prior transplantectomy and is associated significantly with graft and patient survival; similar results were found by Sumrani et al [10], who conclude that those higher levels of PRA influenced detriment of new allograft. PRA level was also studied by Douzjian et al [5], but they observed that an increased level of PRA was not associated with survival; the same results were found by Surga et al [6]. In our series, we found that prior nephrectomy was significantly associated with higher levels of PRA. But we did not find differences at multivariate analysis, using Cox logistic regression. So we conclude that there are differences in terms of PRA levels, and graft or patient survival is influenced by that. Our results showed that hemodialysis duration was longer in patient with previous transplantectomy, but we found no association between that and graft or patient survival. Posttransplantectomy care and the healing of the abdominal wall may be causes of this delay. Similar results were found by Ahmad et al [4]. Yangmurdur et al [7] also found an adverse association between this and new graft failure. In contrast, Dinis et al [8] did not find differences in hemodialysis duration between groups. We had a higher proportion of patients with delayed graft function. A similar tendency was found by Schleicher et al [9]. This effect can be due to immunologic causes. Contrary
GRAFT SURVIVAL OF SECOND ALLOGRAFTS
2897 Table 1. Demographic Characteristics
Patient and donor characteristics Patient age (y) Donor age (y) Recipient sex Male Female Donor sex Male Female Donor type Cadaveric Alive Body mass index Diabetes mellitus No Yes Retransplantation characteristics Hemodialysis duration Cold ischemia duration Blood transfusion No Yes Overall PRA Average HLA mismatch Overall patient status Alive Dead Overall patient survival (mo) 5-y patient status Alive Dead 5-y patient survival (mo) Overall graft status Functional Nonfunctional Overall graft survival (mo) 5-y graft status Functional Nonfunctional 5-y graft survival (mo) MDRD4 1y 5y Acute rejection Yes No Chronic reject Yes No Delayed graft function, yes
Overall
Transplantectomy
No Transplantectomy
Significance
43.2 13.8 46.0 16.8
43.4 14.5 43.2 15.7
42.8 12.6 47.5 17.3
NS (P ¼ .844)* NS (P ¼ .240)* NS (P ¼ .202)†
38 (60.3%) 25 (39.7%)
15 (74.1%) 6 (28.6%)
23 (54.8%) 19 (45.2%)
41 (77.4%) 12 (22.6%)
15 (78.9%) 4 (21.1%)
26 (76.5%) 8 (23.5%)
NS (P ¼ .836)
NS (P ¼ .310)† 61 (96.8) 2 (3.2%) 26.8 6.7
21 (100%) 0 (0%) 25.9 7.8
61 (96.8%) 2 (4.8%) 27.3 6.2
39 (77.2%) 15 (27.8%)
14 (70.0%) 6 (30.0%)
25 (73.5%) 9 (26.5%)
84.7 73.4 16.3 7.3
112.2 72.8 15.5 5.6
70.9 66.9 16.8 8.0
29 (69%) 13 (31%) 61.0 29.4 3.2 1.2
13 (86.7%) 2 (13.3%) 72.0 25.3 3.1 1.1
16 (59.3%) 11 (40.7%) 54.8 30.0 3.2 1.2
43 (68.3%) 20 (31.7%) 98.3 61.8
13 (61.9%) 8 (38.1%) 125.0 55.4
30 (71.4%) 12 (28.6%) 85.0 61.0
53 (84.1%) 10 (15.9%) 50.2 18.8
20 (95.2%) 1 (4.8%) 56.5 14.2
33 (78.6%) 9 (21.4%) 47.0 20.0
35 (56.6%) 28 (44.4%) 57.6 59.3
12 (57.2) 9 (42.8%) 74.2 63.2
23 (54.8%) 19 (54.2%) 49.2 42.6
41 (65.1%) 22 (34.9%) 37.1 25.9
13 (61.9%) 8 (38.1%) 39.4 27.1
28 (66.7%) 14 (33.3%) 35.9 25.5
53.2 20.0 51.4 21.5
53.3 19.8 53.2 27.2
53.1 20.4 49.7 15.8
12 (19%) 47 (74.6%)
5 (25.0%) 15 (75.0%)
7 (17.4%) 32 (82.1%)
1 (1.6%) 58 (92.1%) 19 (30.2%)
0.0 (0%) 20.0 (100%) 10 (58.8%)
1 (7.6%) 38 (97.4%) 9 (27.3%)
NS (P ¼ .560) NS (P ¼ .780)
P ¼ .023* NS (P ¼ .530)* NS (P ¼ .660)
P ¼ .040* NS (P ¼ .620)* NS (P ¼ .444)†
P ¼ .015* NS (P ¼ .088)†
P ¼ .039* NS (P ¼ .858)†
NS (P ¼ .160)* NS (P ¼ .764)†
NS (P ¼ .545)* NS (P ¼ .974)* NS (P > .999)* NS (P ¼ .524)†
NS (P ¼ .470)†
P ¼ .029*
Abbreviations: MDRD4, Modification of Diet in Renal Diseasee4; NS, not significant; PRA, panel-reactive antibody. *Mann-Whitney U test. † 2 c test.
to Schleicher et al [9], no association was found with graft survival. Finally, we found no association between failed graft nephrectomy and patient or graft survival with the Kaplan-
Meier test. Those results are contrary to the ones obtained by Sumrani et al [10] and Schleicher et al [9]. But our results are in accordance with those obtained by Ahmad et al [4], Ayus et al [11], and Yagmurdur et al [7].
2898
SÁNCHEZ-GONZÁLEZ, CARRASCO-VALIENTE, ARENAS-BONILLA ET AL
Fig 1. Kaplan Meier test for patient or graft survival.
CONCLUSION
There may be a beneficial effect of transplantectomy on patient or graft survival by performing failed graft nephrectomy before retransplantation, but no significant differences between performing or not performing transplantectomy were found. Higher levels of PRA, a higher proportion of patients with delayed graft function, and longer hemodialysis were found in the transplantectomy group. REFERENCES [1] Morales A, Gavela E, Kanter J, et al. Treatment of renal transplant failure. Transplant Proc 2008;40:2909. [2] Ojo A, Wolfe RA, Agodoa LY, et al. Prognosis after primary renal transplant failure and the beneficial effects of repeat transplantation: multivariate analysis from the United States Renal Data System. Transplantation 1998;66:1651. [3] Kayler LK, Mohanka R, Basu A, Shapiro R, Randhawa PS. Correlation of histologic findings on preimplant biopsy with kidney graft survival. Transpl Int 2008;21:892. [4] Ahmad N, Ahmed K, Mamode N. Does nephrectomy of failed allograft influence graft survival after re-transplantation? Nephrol Dial Transplant 2009;24:639.
[5] Douzdjian V, Rice JC, Carson RW, et al. Renal retransplants: effect of primary allograft nephrectomy on early function, acute rejection and outcome. Clin Transplant 1996;10:203. [6] Surga N, Viart L, Wetzstein M, et al. Impact of renal graft nephrectomy on second kidney transplant survival. Int Urol Nephrol 2013;45:87e92. [7] Yagmurdur MC, Emiroglu R, Ayvaz I, Sozen H, Karakayali H, Haberal M. The effect of graft nephrectomy on longterm graft function and survival in kidney retransplantation. Transplant Proc 2005;37:2957. [8] Dinis P, Nunes P, Marconi L, et al. Kidney retransplantation: removal or persistence of the previous failed allograft? Transplant Proc 2014;46:1730e1734. [9] Schleicher C, Wolters H, Kebschull L, et al. Impact of failed allograft nephrectomy on initial function and graft survival after kidney retransplantation. Transpl Int 2011;24:284e91. [10] Sumrani N, Delaney V, Hong JH, et al. The influence of nephrectomy of the primary allograft on retransplant graft outcome in the cyclosporine era. Transplantation 1992;53:52. [11] Ayus JC, Achinger SG, Lee S, Sayegh M, Go AS. Transplant nephrectomy associates with improved survival in patients with failed renal allograft. J Am Soc Nephrol 2010;21:374. [12] Mazzucchi E, Nahas WC, Antonopoulos IM, et al. Surgical complications of graft nephrectomy in the modern transplant era. J Urol 2003;170:734.
ABSTRACT Introduction. Nowadays, the number of patients receiving a second graft is growing, and the management of failed grafts is still controversial. Objective. Our objective was to analyze the influence of graft nephrectomy on graft and patient survival. Materials and Methods. We retrospectively evaluated the demographic features and graft outcomes of 63 recipients who received second allografts between August 1985 and April 2013. They were divided into two groups: group A, those who underwent nephrectomy of failed graft (n ¼ 21, 33.3%), and group B, those whose failed graft was retained (n ¼ 42, 66.6%). c2 and Mann-Whitney U tests were used to compare demographic characteristics and graft features in both groups. Kaplan-Meier test was used to analyze graft and patient survival. Finally, univariate and multivariate analysis was done using Cox regression. Results. Demographic characteristics of donor and receptors were similar in both groups. Overall panel-reactive antibody (P ¼ .040) showed statistically significant differences between groups (72.0 25.3 in group A and 54.8 30.0 in group B). Hemodialysis duration was longer in group A (P ¼ .023, 112.2 72.8 vs 70.9 66.9 months). The percentage of patients who had delayed graft function was higher in group A (58.8% vs 27.3%, P ¼ .029). Kaplan-Meier test found no differences between groups (P ¼ .344); group A, 107.4 months (95% confidence interval [CI] 74.0 to 140.8) and group B, 82.7 months (95% CI 62.5 to 102.8). We found no differences in terms of patient survival (P ¼ .798) with the Kaplan-Meier test. In group A, patient survival was 164.5 months (CI 137.7 to 191.31) and in group B, 152.0 months (95% CI 125.5 to 178.5). Conclusions. Failed graft nephrectomy did not show a negative impact on graft and patient survival.
A
LTHOUGH several advances have been made in kidney transplantation outcomes, graft failure still affects up to 10% of renal transplants [1]. In those cases, repeat transplantation improves overall patient survival [2]; however, outcomes of second grafts still lag behind of those of primary grafts [3]. Several studies have investigated the effect of failed graft nephrectomy on retransplantation outcome [4e9], but the management of asymptomatic failed allograft remains controversial. ª 2016 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 48, 2895e2898 (2016)
The aim of our study was to analyze the impact of failed graft nephrectomy on a subsequent transplantation, by comparing graft and patient survivals of those patients with transplantectomy prior to second transplantation against those without transplantectomy.
*Address correspondence to Álvaro Sánchez-González, Hospital Universitario Reina SofíaeIMIBIC, Avenida Menéndez Pidal s/n, 14004 Córdoba, Spain. E-mail: [email protected] 0041-1345/16 http://dx.doi.org/10.1016/j.transproceed.2016.09.016
2895
2896
SÁNCHEZ-GONZÁLEZ, CARRASCO-VALIENTE, ARENAS-BONILLA ET AL
MATERIALS AND METHODS Between August 1985 and April 2013, 1073 kidney transplantations were performed in our center, including 155 (14.45%) retransplantations. Of the 134 patients who were retransplanted, 42 (3.91%) patients retained the failed graft in situ (group A). We used Microsoft Office Excel 2007 (Redmond, Wash, United States) to generate a list of random values without repetition to perform a simple randomization for group A. All patients (n ¼ 21, 1.96%) who received second allograft and underwent failed graft nephrectomy were selected (group B). Donor and graft data and surgical and follow-up information were collected retrospectively from the local transplantation registry and patients’ medical history files. Primary endpoint was the influence of graft nephrectomy on patient and graft survival. Demographic characteristics, perioperative characteristics, panel-reactive antibody (PRA) levels, delayed graft function, HLA matching, rate of acute rejections, and renal function were also examined. Immunosuppressive therapy is as follows: CellCept (Genentech, San Francisco, Calif, United States) 500 mg every 12 hours; Advagraf 0.2 mg/kg/d; prednisone daily doses between 5 and 20 mg. If there is any intolerance of these drugs, the dosage can be modified. For hyperimmunized patients, donor or receptor or receptor asystole expanded donor criteria, and thymoglobulin induction is performed at 1 mg/kg/dose, 5 doses, beginning pretransplant. Delayed graft function was defined as the postoperative need for dialysis in the first post-transplant week. Glomerular filtration rate was estimated using the abbreviated Modification of Diet in Renal Disease equation. Patient characteristics are presented using mean and standard deviation for continuous variables, and frequencies and proportions for categorical variables. Groups were compared using Mann-Whitney U test for continuous variables and c2 test for categorical ones. Univariate and multivariate Cox regression test was performed. We analyzed the association between transplantectomy and graft and patient survival with the Kaplan-Meier test. All statistical analyses were carried out using SPSS v15.0 (IBM, Amonk, New York, United States) software package. All tests were 2-sided, and P values < .05 were accepted as significant.
RESULTS
Indications for allograft nephrectomy were recurrent urinary tract infections, hematuria, pain, adverse effects of immunosuppressive drugs, tumors, or need to create room for the new graft. The most common cause of end-stage renal failure was glomerulonephritis (n ¼ 21, 33.3%), followed by unknown etiology (n ¼ 16, 25.4%) and vesicoureteral reflux disease (n ¼ 5, 7.4%). We also included patients with diabetic nephropathy and polycystic kidney disease (n ¼ 3, 4.8% in both cases) and malignant hypertension (n ¼ 2, 3.2%) and Alport disease (n ¼ 1, 1.6%) disease. No differences were found when we compared demographic characteristics (Table 1). When retransplantation characteristics were compared, significant differences were found at overall PRA levels, which were higher in the transplantectomy group
(72.0% 25.3% vs 54.8% 30.4%; P ¼ .04). We also found a significantly longer duration of hemodialysis in group B (112.2 72.8 vs 70.9 66.9 months; P ¼ .023). No other differences were found (Table 1). We found statistically significant differences in patient survival, which was longer in the transplantectomy group (125.0 55.4 vs 85.0 61.0 months, P ¼ .015). We also found a higher proportion of patient with delayed graft function in group B (58.8% vs 27.3%, P ¼ .0291). As shown in Table 1, no other differences were found on graft outcome. No statistical association was found with Cox regression multivariate test between the variables used and graft survival. When we analyzed the effect of nephrectomy on patient or graft overall survival by Kaplan-Meier survival test, no association was found (P ¼ .798 and P ¼ .334, respectively, Fig 1). DISCUSSION
Kidney retransplantation improves quality of life and is more cost-effective than hemodialysis and peritoneal dialysis [10]. There is a lack of consensus about the optimal management of the failed renal allograft in patients awaiting retransplantation. Even without any clinical symptoms, retained failed allograft induces chronic inflammatory response syndrome and is associated with higher morbidity on hemodialysis [11]. But, in contrast, perioperative morbidity of graft nephrectomy is considered high (<10%) and mortality is reported between 0.7% and 5% [12]. Ahmad et al [4] showed that PRA level is increased in patients with prior transplantectomy and is associated significantly with graft and patient survival; similar results were found by Sumrani et al [10], who conclude that those higher levels of PRA influenced detriment of new allograft. PRA level was also studied by Douzjian et al [5], but they observed that an increased level of PRA was not associated with survival; the same results were found by Surga et al [6]. In our series, we found that prior nephrectomy was significantly associated with higher levels of PRA. But we did not find differences at multivariate analysis, using Cox logistic regression. So we conclude that there are differences in terms of PRA levels, and graft or patient survival is influenced by that. Our results showed that hemodialysis duration was longer in patient with previous transplantectomy, but we found no association between that and graft or patient survival. Posttransplantectomy care and the healing of the abdominal wall may be causes of this delay. Similar results were found by Ahmad et al [4]. Yangmurdur et al [7] also found an adverse association between this and new graft failure. In contrast, Dinis et al [8] did not find differences in hemodialysis duration between groups. We had a higher proportion of patients with delayed graft function. A similar tendency was found by Schleicher et al [9]. This effect can be due to immunologic causes. Contrary
GRAFT SURVIVAL OF SECOND ALLOGRAFTS
2897 Table 1. Demographic Characteristics
Patient and donor characteristics Patient age (y) Donor age (y) Recipient sex Male Female Donor sex Male Female Donor type Cadaveric Alive Body mass index Diabetes mellitus No Yes Retransplantation characteristics Hemodialysis duration Cold ischemia duration Blood transfusion No Yes Overall PRA Average HLA mismatch Overall patient status Alive Dead Overall patient survival (mo) 5-y patient status Alive Dead 5-y patient survival (mo) Overall graft status Functional Nonfunctional Overall graft survival (mo) 5-y graft status Functional Nonfunctional 5-y graft survival (mo) MDRD4 1y 5y Acute rejection Yes No Chronic reject Yes No Delayed graft function, yes
Overall
Transplantectomy
No Transplantectomy
Significance
43.2 13.8 46.0 16.8
43.4 14.5 43.2 15.7
42.8 12.6 47.5 17.3
NS (P ¼ .844)* NS (P ¼ .240)* NS (P ¼ .202)†
38 (60.3%) 25 (39.7%)
15 (74.1%) 6 (28.6%)
23 (54.8%) 19 (45.2%)
41 (77.4%) 12 (22.6%)
15 (78.9%) 4 (21.1%)
26 (76.5%) 8 (23.5%)
NS (P ¼ .836)
NS (P ¼ .310)† 61 (96.8) 2 (3.2%) 26.8 6.7
21 (100%) 0 (0%) 25.9 7.8
61 (96.8%) 2 (4.8%) 27.3 6.2
39 (77.2%) 15 (27.8%)
14 (70.0%) 6 (30.0%)
25 (73.5%) 9 (26.5%)
84.7 73.4 16.3 7.3
112.2 72.8 15.5 5.6
70.9 66.9 16.8 8.0
29 (69%) 13 (31%) 61.0 29.4 3.2 1.2
13 (86.7%) 2 (13.3%) 72.0 25.3 3.1 1.1
16 (59.3%) 11 (40.7%) 54.8 30.0 3.2 1.2
43 (68.3%) 20 (31.7%) 98.3 61.8
13 (61.9%) 8 (38.1%) 125.0 55.4
30 (71.4%) 12 (28.6%) 85.0 61.0
53 (84.1%) 10 (15.9%) 50.2 18.8
20 (95.2%) 1 (4.8%) 56.5 14.2
33 (78.6%) 9 (21.4%) 47.0 20.0
35 (56.6%) 28 (44.4%) 57.6 59.3
12 (57.2) 9 (42.8%) 74.2 63.2
23 (54.8%) 19 (54.2%) 49.2 42.6
41 (65.1%) 22 (34.9%) 37.1 25.9
13 (61.9%) 8 (38.1%) 39.4 27.1
28 (66.7%) 14 (33.3%) 35.9 25.5
53.2 20.0 51.4 21.5
53.3 19.8 53.2 27.2
53.1 20.4 49.7 15.8
12 (19%) 47 (74.6%)
5 (25.0%) 15 (75.0%)
7 (17.4%) 32 (82.1%)
1 (1.6%) 58 (92.1%) 19 (30.2%)
0.0 (0%) 20.0 (100%) 10 (58.8%)
1 (7.6%) 38 (97.4%) 9 (27.3%)
NS (P ¼ .560) NS (P ¼ .780)
P ¼ .023* NS (P ¼ .530)* NS (P ¼ .660)
P ¼ .040* NS (P ¼ .620)* NS (P ¼ .444)†
P ¼ .015* NS (P ¼ .088)†
P ¼ .039* NS (P ¼ .858)†
NS (P ¼ .160)* NS (P ¼ .764)†
NS (P ¼ .545)* NS (P ¼ .974)* NS (P > .999)* NS (P ¼ .524)†
NS (P ¼ .470)†
P ¼ .029*
Abbreviations: MDRD4, Modification of Diet in Renal Diseasee4; NS, not significant; PRA, panel-reactive antibody. *Mann-Whitney U test. † 2 c test.
to Schleicher et al [9], no association was found with graft survival. Finally, we found no association between failed graft nephrectomy and patient or graft survival with the Kaplan-
Meier test. Those results are contrary to the ones obtained by Sumrani et al [10] and Schleicher et al [9]. But our results are in accordance with those obtained by Ahmad et al [4], Ayus et al [11], and Yagmurdur et al [7].
2898
SÁNCHEZ-GONZÁLEZ, CARRASCO-VALIENTE, ARENAS-BONILLA ET AL
Fig 1. Kaplan Meier test for patient or graft survival.
CONCLUSION
There may be a beneficial effect of transplantectomy on patient or graft survival by performing failed graft nephrectomy before retransplantation, but no significant differences between performing or not performing transplantectomy were found. Higher levels of PRA, a higher proportion of patients with delayed graft function, and longer hemodialysis were found in the transplantectomy group. REFERENCES [1] Morales A, Gavela E, Kanter J, et al. Treatment of renal transplant failure. Transplant Proc 2008;40:2909. [2] Ojo A, Wolfe RA, Agodoa LY, et al. Prognosis after primary renal transplant failure and the beneficial effects of repeat transplantation: multivariate analysis from the United States Renal Data System. Transplantation 1998;66:1651. [3] Kayler LK, Mohanka R, Basu A, Shapiro R, Randhawa PS. Correlation of histologic findings on preimplant biopsy with kidney graft survival. Transpl Int 2008;21:892. [4] Ahmad N, Ahmed K, Mamode N. Does nephrectomy of failed allograft influence graft survival after re-transplantation? Nephrol Dial Transplant 2009;24:639.
[5] Douzdjian V, Rice JC, Carson RW, et al. Renal retransplants: effect of primary allograft nephrectomy on early function, acute rejection and outcome. Clin Transplant 1996;10:203. [6] Surga N, Viart L, Wetzstein M, et al. Impact of renal graft nephrectomy on second kidney transplant survival. Int Urol Nephrol 2013;45:87e92. [7] Yagmurdur MC, Emiroglu R, Ayvaz I, Sozen H, Karakayali H, Haberal M. The effect of graft nephrectomy on longterm graft function and survival in kidney retransplantation. Transplant Proc 2005;37:2957. [8] Dinis P, Nunes P, Marconi L, et al. Kidney retransplantation: removal or persistence of the previous failed allograft? Transplant Proc 2014;46:1730e1734. [9] Schleicher C, Wolters H, Kebschull L, et al. Impact of failed allograft nephrectomy on initial function and graft survival after kidney retransplantation. Transpl Int 2011;24:284e91. [10] Sumrani N, Delaney V, Hong JH, et al. The influence of nephrectomy of the primary allograft on retransplant graft outcome in the cyclosporine era. Transplantation 1992;53:52. [11] Ayus JC, Achinger SG, Lee S, Sayegh M, Go AS. Transplant nephrectomy associates with improved survival in patients with failed renal allograft. J Am Soc Nephrol 2010;21:374. [12] Mazzucchi E, Nahas WC, Antonopoulos IM, et al. Surgical complications of graft nephrectomy in the modern transplant era. J Urol 2003;170:734.