Selective Retransplant After Graft Loss to Nonadherence: Success with a Second Chance

• Published in: American journal of transplantation Vol. 9; no. 6; pp. 1337 - 1346
• Main Authors: Dunn, T. B., Browne, B. J., Gillingham, K. J., Kandaswamy, R., Humar, A., Payne, W. D., Sutherland, D. E. R., Matas, A. J.
• Format: Journal Article
• Language: English
• Published: Malden, USA Blackwell Publishing Inc 01-06-2009; Wiley
• Subjects: Adult; Biological and medical sciences; Female; Graft Rejection - etiology; Graft Survival - immunology; Humans; Kidney Transplantation - immunology; Kidney Transplantation - mortality; Male; Medical sciences; Middle Aged; nonadherence; Noncompliance; outcome; Patient Care Team; Patient Compliance; Patient Selection; Reoperation; retransplant; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Tissue and Organ Procurement; Treatment Outcome; Prognosis; Treatment; Compliance; Surgery; retransplant; Loss; nonadherence; Evolution; Graft; Noncompliance; outcome
• ISSN: 1600-6135; 1600-6143
• DOI: 10.1111/j.1600-6143.2009.02625.x

Nonadherence (NA) is a difficult posttransplant problem that can lead to graft loss. A retransplant is controversial because of a fear of recurrent NA. We reviewed our center's data base and identified 114 kidney recipients who lost their graft to overt NA; of this group, 35 (31%) underwent a retransplant after a thorough reevaluation. We compared this NA retransplant group to a control group of second transplant recipients who did not lose their first graft to overt NA (non‐NA) (n = 552). After 8 years of follow‐up, we found no significant differences between the groups in actuarial graft or patient survival rates, renal function, or the incidence of biopsy‐proven chronic rejection. However, 5 of 35 (14%) NA recipients versus 10 of 552 (2%) non‐NA recipients lost their retransplant to NA (p = 0.0001). Twenty of 35 (57%) of the NA group exhibited repeat NA behavior after retransplant. We conclude that prior graft loss to NA is associated with increased graft loss to NA after retransplant. However, the majority of NA retransplant recipients did well—with overall long‐term outcomes similar to those of the non‐NA group. With careful patient selection and aggressive intervention, prior overt NA should not be an absolute contraindication to retransplantation.
Kidney retransplant after graft loss secondary to nonadherence is successful in the majority of patients, but this population experienced more acute rejection and repeat graft loss to nonadherence as compared to a historical cohort of ‘adherent’ retransplant recipients. See Editorial by Curtis on page 1261–1262.