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REPEAT RENAL TRANSPLANTATION

J T Jagose, U G Oza*, B Kashyapi*, S W Thatte*, C A Somaya*, A L Kirpalani,
A G Phadke*
Depts. of Nephrology and Renal Transplantation*, Bombay Hospital Institute of Medical Sciences, Mumbai.

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Renal transplantation is a definitive treatment for end-stage renal failure. Despite economic limitations, patients with a failed primary graft still opt for a second renal transplant for better rehabilitation and an improved quality of life. Our report describes the outcome of renal retransplantation at this institution. Over a 10 year period, 418 renal transplants were performed, 395 being primary. Twenty-three patients (18 male, mean age 46.5 yr, 22 living unrelated donors) underwent a second renal transplant after loss of their primary graft (chronic rejection 15, non-compliance 4, technical failure 2, hyperacute rejection 1, cardiac arrhythmia 1). The immunosuppressive regimen included prednisone, azathioprine and cyclosporin. Satisfactory 1 and 3 year patient and graft survival were noted. 1 yr patient and graft survival 90% and 86% and 3 yr patient and graft survival 69% and 62% respectively. Graft loss after retransplantation occurred in 6 patients primary non-function 2, chronic rejection 2, pulmonary infection 2. The results are encouraging and we suggest that repeat renal transplantation be offered to patients with a failed primary graft as an alternative to life-long dialysis.

INTRODUCTION

After the loss of a primary renal allograft, patients with end-stage renal failure have few alternatives available to them. These include long term dialysis or death from renal failure or a second renal transplant. A successful second renal transplant will provide the best degree of rehabilitation. [2]

In this report we have reviewed the outcome of renal retransplantation at this institution.

PATIENTS AND METHODS

The repeat renal transplants undertaken in this unit between April 1984 and March 1995 were audited. All grafts were obtained from live donors. Tissue typing with 1 HLA-B and 1 HLA-DR antigen match with a negative direct white cell (HLA) crossmatch was mandatory before further investigation of the donor. The immunosuppressive regimen consisted of (a) cyclosporin 10 mg/kg orally pre-operatively tapered to 4 mg/kg/12 hr by day 7, and then to 2 mg/kg/12 hr at the end of 3 months; (b) azathioprine 5 mg/kg orally pre-operatively tapered to 1.5 mg/kg/day by 3 months and (c) prednisone 2 mg/kg/day orally pre-operatively tapered to 0.5 mg/kg/day by 4 weeks. Acute rejection episodes were treated with intravenous methylprednisolone 0.5-1 g daily for at least 3 doses, with OKT 3 or ALG reserved for steroid resistant rejection episodes.

RESULTS

Between April 1984 and March 1995, 418 renal transplants were performed, 395 being primary and 23 retransplants. The clinical details of these 23 patients are included in Table 1.

DISCUSSION

This study of patients having a second renal transplant has shown satisfactory 1 and 3 year graft and patient survival. The immunosuppressive regimen was similar to that used for primary grafts; however, we were more aggressive in treating rejection episodes in second transplants by instituting therapy earlier.

TABLE 1 Clinical details of all 23 patients having a second renal transplant
No. of patients	23
Male/Female	18/5
Mean age	46.5 yr. (range 32-58)
Live unrelated donor/live related donor	22/1
Cause of primary graft loss
Chronic rejection	15
Non-compliance leading to rejection	Non-compliance leading to rejection
Technical failure	2
Hyperacute rejection	1
Cardiac arrhythmia with hypotension	1
Graft loss after retransplantation	2
Primary non-function	2
Chronic rejection	2
Pulmonary Infection	2
Survival
1 yr
patient	90%
graft	86%
3 yr
patient	69%
graft	32%

The problem of non-compliance with immunosuppressive therapy has emerged as a major cause of graft loss in renal transplant recipients. [2-4] Four patients lost their first graft as a result of non-compliance but underwent a second transplant and have been compliant with therapy since. Six of the second grafts were lost - primary non-function 2, chronic rejection 2 and pulmonary infection 2.

From our experience the results of second renal transplants are encouraging and offer patients a better quality of life. Moreover, the cost of a successful second transplant will eventually provide a savings benefit to alternative life-long dialysis. [5] We therefore suggest that the option of a second renal transplant be offered to patients with a failed primary allograft despite socio-economic constraints.

REFERENCES

1. Evans RW. A cost-outcome analysis of retransplantation : the need for accountability. Transpl Rev 1993; 7 : 163-75.
2. Rovelli M, Palmeri D, Vossler E, Bartus S, Hull D, Schweizer R. Non-compliance in organ transplant recipients. Transpl Proc 1989; 21 : 833-34.
3. Delmonico FL, Tolkoff-Rubin N, Auchincloss H, Jr et al. Second renal transplantations : ethical issues clarified by outcome; outcome enhanced by a reliable cross-match. Arch Surg 1994; 129 : 354-60.
4. Troppman C, Benedetti E, Gruessner RWG, et al. Retransplantation after renal allograft loss due to non-compliance. Transpl 1995; 59 : 467-71.
5. US Renal Data System. USRDS 1993 Annual Data Report : prevalence and cost of ESRD therapy. Am J Kid Dis 1993; 22 : 21-29.

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