Answer: Remarkable strides have been witnessed in the transplantation of solid organs over the past two decades. This is evidenced by the reduction in the incidence of acute rejection one year following the transplant procedure and by the improved long-term overall graft (transplanted organ) survival. Nevertheless, thousands of patients find themselves returning to dialysis yearly as a result of their transplanted kidney having failed. The indications for returning to dialysis would be similar to those that led to the initiation of dialysis after failure of native kidney function (assuming the patient dialyzed pre-transplantation, since a small percentage of patients undergo "preemptive" transplantation - not having been dialyzed before receiving a kidney, usually from a living donor). If the patient had been followed closely by his or her nephrologist, the access for dialysis should have been secured in advance of returning to dialysis, either by placement of a peritoneal dialysis catheter if the patient elects to do peritoneal dialysis, or ensuring there is a working arteriovenous fistula or graft for hemodialysis. The timing for access placement in this setting is similar, once again, to that for native kidney failure, when the creatinine clearance is 20 ml/min or less in non-diabetics and 25 ml/min or less in diabetic patients. This point is usually reached only after the patient has undergone a biopsy at some point to validate that there is very little to no possibility that the transplanted kidney can recover sufficient function with additional or continued immunosuppression.

Obviously, the transition back to dialysis following a failed kidney transplant is fraught with change. The most easily recognizable changes are in lifestyle - following a prescribed diet in terms of limiting salt and water intake, as well as foodstuffs that are rich in potassium and phosphorous, depending upon how much residual kidney function the patient may possess. The anemia that usually abates (lessens) following a successful kidney transplant will likely recur if a transplant fails, so a patient will need to go back on erythropoietin and iron supplements. Phosphorous supplements and multivitamins are also likely to be prescribed. A new "dry weight" will need to be established upon return to dialysis as well.

While new medications are being prescribed that accompany a return to dialysis, other medications that were prescribed for the transplanted kidney are tapered or discontinued. Both the transplanted patient and the dialysis patient are at increased risk for serious infections and certain cancers, the former because of the immunosuppressant drugs and the latter for the immunodeficient state of uremia. Therefore, the patient with the failed kidney transplant who returns to dialysis is best served by having reductions made in their immunosuppressive medications.

Most nephrologists will instruct the patient to discontinue their calcineurin inhibitor (i.e. cyclosporine or tacrolimus)drug outright with no tapering schedule. Should the patient either be on azathioprine, mycophenolate, or sirolimus, these drugs are usually discontinued or tapered off over several months. More importantly, should the patient still be on prednisone or medrol at the time of returning to dialysis, these corticosteroid drugs are tapered off very cautiously, unless there is an overriding medical condition (e.g. lupus), which mandates their continued administration. Should the corticosteroids be discontinued abruptly, the patient may suffer from adrenal insufficiency, resulting in circulatory collapse. The adrenal glands are shut down from producing its own hormones while the patient is taking administered corticosteroids over an extended period of time. Some signs and symptoms that a patient may be experiencing adrenal insufficiency, other than overt hypotension or marked low blood pressure, are continued malaise (lethargy) and fatigue, unexplained low-grade fever, weakness, myalgias (muscle pain) and arthralgias (joint pain) and weight loss from poor appetite.

A major concern of both patient and nephrologist that arises with the discontinuation of the immunosuppressives upon returning to dialysis is the possibility of rejection. The incidence for the need of surgical removal of the kidney, or nephrectomy, has been cited to vary between 20 and 65 percent over the past two decades. The indications for such a removal include pain and graft tenderness, otherwise unexplained fever, blood in the urine (hematuria), and a failure to thrive. Transplant kidneys, which lose function within a year following transplantation, are also usually surgically removed to stave off the possibility of other possible complications arising, such as thrombosis and hemorrhage.

The patient who returns to dialysis following a failed kidney transplant needs to play an active role in his or her own healthcare. He or she needs to follow the prescribed diet and medications, stay physically active and keep whatever appointments may have been made for cancer screening examinations (e.g. colonoscopy, mammography, etc.) and coronary disease testing. They also need to report any symptoms to their dialysis team that may be related to their failed kidney transplant mentioned above. Lastly, they should seek out relisting on their local organ procurement organization waiting list or identify any possible living donor to their dialysis healthcare team.

Question answered by Ken Bodziak, MD. Dr. Bodziak is an Assistant Professor of Medicine in the Division of Nephrology at University Hospitals of Cleveland. He was previously at Beaumont Hospital in Royal Oak, MI, where he participated in the renal transplant program as a transplant nephrologist.

The Dear Doctor column provides readers with an opportunity to submit renal related health questions to healthcare professionals who specialize in the area of concern. The answers are not to be construed as a diagnosis and therefore, altercations in current healthcare should not occur until the patient's physician is consulted.

This article originally appeared in the March 2002 issue of aakpRENALIFE, Vol. 17, No. 5.

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