Management of allograft loss requires teamwork, patient involvement
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Tarek Alhamad, MD, has witnessed the grief that patients with a kidney transplant experience when they are facing loss of an allograft.
“It is definitely one of the hardest discussions that we could have as transplant nephrologists with the transplant recipient,” Alhamad, associate professor of medicine and medical director of the kidney transplant program in the division of nephrology at the Washington School of Medicine at St. Louis, told Healio/Nephrology News & Issues. “Going back to dialysis is something that would change their life completely with less quality of life and major dependence on a machine to continue to survive.”
Source: Tarek Alhamad, MD
Mary Beth Callahan, ACSW/LCSW-APHSW-C, the Supportive Care Team program manager and senior social worker at Dallas Nephrology Associates and Dallas Transplant Institute, has been counseling such patients for more than 30 years and helps with the potential changes that may result from a failing allograft.
“It’s important to discuss information about waiting time, risks of a second, third or fourth transplant, risks of dialysis and, depending on age, morbidity and motivation, active medical management without dialysis as an option,” Callahan said.
Likewise, with an inadequate organ supply, patients may see their opportunities for a second transplant as limited. “With the long-standing organ shortage, we know that having a living donor transplant will be the only way many patients receive a preemptive transplant,” Callahan said. “It is my impression that sometimes, patients and care partners can feel lacking if they cannot ‘find’ a living donor. This can be another loss in a series of losses that one deals with during chronic illness.”
Risks of re-transplant
There are major risks that patients with end-stage kidney disease face when their allograft fails.
“Patients with a failed allograft are at higher risk of mortality after starting dialysis compared to those who were never transplanted,” Alhamad and colleagues wrote in a paper published in the American Journal of Transplantation. “Previous papers suggest that this increased mortality is primarily due to cardiac (36%) or infection complications (17%). Maintaining full immunosuppression has been associated with increased risk of hospitalization and infection within 6 months of starting dialysis.
“On the other hand, the presence of a failed allograft in ESKD patients who had complete withdrawal of immunosuppressive therapies is associated with higher [C-reactive protein] CRP levels, lower albumin, and decreased muscle mass compared to those who were never transplanted,” they wrote.
In 2021, transplant centers performed 2,474 repeated kidney transplants, an increase from 2,175 the previous year, according to data from the United Network for Organ Sharing (see Table).
Those issues make patient management critical, Prince Mohan Anand, MD, FACP, FASN, FAST, director of the transplant service and clinical associate professor of medicine and surgery in the division of nephrology and transplant surgery at the Medical University of South Carolina, told Healio/Nephrology News & Issues, particularly if a second transplant is being considered.
“There are studies done that show that mortality is higher among patients going from a failing allograft to transplant vs. dialysis to transplant,” Anand said. “The higher risk has to do with sensitization, the risk for forming donor specific antibodies and other concerns.”
Transplants can fail for several reasons, Anand said, with infection of the organ topping the list. “We also see cancers, slow smoldering rejection and cardiovascular-related issues.
“We are doing better with these factors, but some things are inevitable. The risk of cancer has stayed constant over the years,” Anand said.
Asking patients to go through the evaluation process for a second transplant is challenging, but necessary, Callahan said, to make sure the needed support is available.
“Going through the entire evaluation is draining on patients. Often, they feel like they have managed a transplant for a number of years, so why should they have to go through the process again?
“Medical and psychosocial risks change over time,” Callahan said. “It is important to rule out any known risk of cancer or heart disease that could put the person at a higher chance for complications in a second transplant.
“During a past transplant a person may have had a great support system but since then, a spouse has died, siblings have died [or] parents are unable to help due to their own health,” Callahan said.
Patient organizations, such as the Renal Support Network, also can help patients through an allograft loss, Callahan said. President and founder Lori Hartwell, who has had four kidney transplants, offers patient education, podcasts and support groups through the organization’s website (www.rsnhope.org). “It includes views of patients from different walks of life, in different stages of life, sharing their journey with kidney disease and sharing hope,” Callahan said.
Nutrition
Similar to coping with the likelihood of returning to dialysis or facing the procedure for the first time, patients with a failing allograft have to make adjustments to their diet.
“Kidney transplant patients are so happy when they have a well-functioning transplant, and they do not have to take phosphorus binders anymore,” Mary B. Sundell, MLAS, RD, LDN, CSR, FNKF, a renal dietitian in the Medical Specialties Clinic at Vanderbilt Medical Center, told Healio/Nephrology News & Issues. “In fact, many need to be supplemented with phosphorus to keep their levels in range.”
The lack of limit on drinking when there is a transplant is also a difficult transition to dialysis, Sundell said. “ ... [T]hey are encouraged to have a robust fluid intake to stay well-hydrated when their transplant is functional. It is a difficult change to have to limit phosphorus and fluids once again.”
As the allograft fails, Sundell said other nutrition-related interventions “may include lower animal protein intake with a focus on a plant-based diet, lower sodium intake, weight control or nutrition management to avoid malnutrition-inflammation complex syndrome or protein energy wasting,” she said.
Practice guidelines
A series of surveys launched by the American Society of Transplantation (AST) on treating patients with failing allografts has led to a set of practice guidelines to help transplant physicians provide optimal care.
The surveys, bundled under the name Kidney Recipients with Allograft Failure, Transition of Kidney Care, or KRAFT, were launched in 2020 by AST’s Kidney Pancreas Community of Practice workgroup and distributed to AST members.
“We just completed another survey targeting general nephrologists to get their perspectives” on managing the failed allograft, Alhamad told Healio/Nephrology News & Issues. “The series of the surveys will not be completed without getting the patients’ view.”
In the initial survey among transplant providers (n = 104) from 92 kidney transplant centers, “more than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty and side effects of medications,” Alhamad and colleagues wrote in a report about the survey in the American Journal of Transplantation. “The majority of respondents also reported that 50% or less of patients with failed allografts were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis.”
A lack of communication between transplant centers and general nephrologists about the transition of care for patients was the most surprising finding of the survey, Alhamad said, along with the wide range of practices for withdrawal of immunosuppression. “Relisting is almost always a request from patients,” Alhamad said. “Many would try to find a living donor before they get back on dialysis.”
The practice guidelines cover decisions for the management of patients who are candidates for re-transplant, as well as patients who will be directed to dialysis. Topics include recommendations on tapering immunosuppressive drugs, management of CKD issues and how to re-enter patients on to the transplant waitlist or prepare them for dialysis.
The intent of the practice guidelines, wrote Michelle Lubetzky, MD, an associate professor of medicine in the division of nephrology at the University of Texas at Austin, Dell-Seton Medical Center, and colleagues in the American Journal of Transplantation was to aid in the “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.”
Easing the vulnerability of patients who see the benefits of transplantation slip away is why a multidisciplinary approach is needed, Callahan said. “It’s important to listen to what matters to the patient ... as health care professionals, working as a team, we need to reinforce learning in multiple discussions as a person’s readiness to accept change evolves.”
- References:
- Alhamad T, et al. Am J Transplant. 2021;doi:10.1111/ajt.16523.
- Lubetzky M, et al. Am J Transplant. 2021;doi:10.1111/ajt.16717.
- Organ Procurement Transplant Network, national data, transplants, 2022. https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/ Accessed Oct. 25, 2022.
- For more information:
- Tarek Alhamad, MD, can be reached at talhamad@wustl.edu.
- Prince Mohan Anand, MD, FACP, FASN, FAST, can be reached at mohanp@@musc.edu.
- Mary Beth Callahan, ACSW/LCSW-APHSW-C, can be reached at callahanm@dneph.com.
- Mary B. Sundell, MLAS, RD, LDN, CSR, FNKF, can be reached at mary.b.sundell@vumc.org.
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