The Failing Kidney Allograft

A Review and Recommendations for the Care and Management of a Complex Group of Patients

Michelle Lubetzky; Ekamol Tantisattamo; Miklos Z. Molnar; Krista L. Lentine; Arpita Basu; Ronald F. Parsons; Kenneth J. Woodside; Martha Pavlakis; Christopher D. Blosser; Neeraj Singh; Beatrice P. Concepcion; Deborah Adey; Gaurav Gupta; Arman Faravardeh; Edward Kraus; Song Ong; Leonardo V. Riella; John Friedewald; Alex Wiseman; Amtul Aala; Darshana M. Dadhania; Tarek Alhamad


American Journal of Transplantation. 2021;21(9):2937-2949. 

In This Article

Abstract and Introduction


The return to dialysis after allograft failure is associated with increased morbidity and mortality. This transition is made more complex by the rising numbers of patients who seek repeat transplantation and therefore may have indications for remaining on low levels of immunosuppression, despite the potential increased morbidity. Management strategies vary across providers, driven by limited data on how to transition off immunosuppression as the allograft fails and a paucity of randomized controlled trials to support one approach over another. In this review, we summarize the current data available for management and care of the failing allograft. Additionally, we discuss a suggested plan for immunosuppression weaning based upon the availability of re-transplantation and residual allograft function. We propose a shared-care model in which there is improved coordination between transplant providers and general nephrologists so that immunosuppression management and preparation for renal replacement therapy and/or repeat transplantation can be conducted with the goal of improved outcomes and decreased morbidity in this vulnerable patient group.


Returning to dialysis after transplantation is a complex transition. Currently, the number of patients returning to dialysis after a failed kidney transplant is steadily rising.[1] Furthermore, dialysis after graft loss (DAGL) is associated with increased mortality.[2] Patients with failed allografts may encounter difficulties in the transition of care back to referring nephrologists, who may not be familiar with the management and goals of immunosuppression after allograft loss. Unfamiliarity with immunosuppression management and communication barriers between transplant centers and general nephrologists resuming care may lead to unfavorable outcomes. Continuation of immunosuppressive therapies may be associated with increased infections and mortality.[3] Despite those risks, remaining on low dose immunosuppression may be associated with some benefits such as preventing sensitization, decreasing the risk of graft intolerance syndrome (GIS), and maintaining residual kidney function.

In this review, we will discuss the current challenges in the management of a patient with a failing allograft, including the risks and benefits of maintaining immunosuppression, management of rejection and graft intolerance syndrome, and propose a shared care model between transplant nephrologists and general nephrologists during this multi-faceted transition period. This manuscript is a work product of the American Society of Transplantation (AST) Kidney and Pancreas Community of Practice (KPCOP) "Kidney Recipients with Allograft Failure–Transition of Care" (KRAFT) work group.