Abstract
Purpose
Management of a failed kidney allograft, and the question whether it should be removed is a challenging task for clinicians. The reported risks for transplant nephrectomy (TN) vary, and there is no clear recommendation on indications or surgical approach that should be used. This study gives an overview of indications, compares surgical techniques, and identifies risk factors for higher morbidity.
Methods
Retrospective analysis was conducted on all transplant nephrectomies performed between 2005 and 2020 at Charité Hospital Berlin, Department of Urology. Patient demographics, laboratory parameters, graft survival data, indication for TN, and surgical complications were extracted from medical reports.
Results
A total of 195 TN were performed, with graft intolerance syndrome being the most common indication in 52 patients (26.7%), acute rejection in 36 (18.5%), acute infection in 30 (15.4%), and other reasons to stop immunosuppression in 26 patients (13.3%). Rare indications were vascular complications in 16 (8.2%) and malignancies in the allograft in six (3.1%) cases. Extracapsular surgical approach was significantly more often used in cases of vascular complications and earlier allograft removal, but there was no difference in complication rates between extra- and intracapsular approach. Acute infection was identified as an independent risk factor for a complication grade IIIb or higher according to Clavien–Dindo classification, with a HR of 12.3 (CI 2.2–67.7; p = 0.004).
Conclusion
Transplant nephrectomy should only be performed when there is a good indication, and non-elective surgery should be avoided, when possible, as it increases morbidity.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Kidney transplantation is the therapy of choice for end stage renal disease and, therefore, numbers of patients who received a graft have been rising [1]. Transplant failure (TF) in the first year is about 9–11%, increasing to about 23–38% after 5 years and 54–66% after 10 years [2]. After kidney TF surgical removal of the allograft has to be evaluated. Whereas there are rarely debated indications for transplant nephrectomy (TN), such as arterial or venous thrombosis, acute rejection or infection of the allograft, indications for TN in chronic transplant failure are not as clearly defined [3], resulting in TN rates between 4.5 and 84.4% depending on centers policy [4]. Possible positive effects of retaining the transplant, such as erythropoetin (EPO) production, residual kidney function, or avoiding risks for morbidity and mortality through the operative procedure, have to be weighed against retaining a nonfunctional allograft as a cause for chronic inflammation or development of a graft intolerance syndrome (GIS) presenting with allograft tenderness, fever, and hematuria [4, 5].
Besides the operative risks, TN is considered as an event of immunization, causing higher levels of panel reacting antibodies (PRA) in patients who had undergone TN, compared to patients who retained their allograft, resulting in a higher risk for delayed graft function or primary non-function after re-transplantation [6,7,8].
Once decision for TN is made, there are two surgical approaches: an extracapsular approach where the complete allograft is removed with its capsule, compared to an intracapsular approach where the plane between parenchyma and capsule is developed to excise the kidney [9]. However, combinations of both techniques are often used depending on intraoperative findings and possibility to develop the different planes.
After TF, considering all these factors for decision-making can be a challenging task for clinicians and, therefore, indication and timing of the procedure must be evaluated carefully. This study aims to show TN results of a single transplant center, regarding indication, complications, surgical approach, and TN outcome.
Materials and methods
Patients and parameters
For this study, all adult patients who underwent TN between January 2005 and February 2020 at Charité Hospital Berlin, Department of Urology, were analyzed retrospectively. Patient demographics, laboratory parameters and graft survival data including clinical information on indication for TN and surgical complications were extracted from their medical reports. This study was performed according to the ethical approval of the institutional review board.
Surgical technique
TN was performed either by extracapsular or intracapsular approach depending on anatomical conditions, time after transplantation and surgeons’ preferences. For intracapsular TN, the capsule was incised, and the transplant was dissected within the capsule, whereas the ureter and capsule remained in situ. For extracapsular approach, the transplant was removed with the capsule. In cases with combinations of both surgical techniques, the determination to either method for further evaluation in this study, was made based on the predominantly used technique according to the surgeon’s report. Drain and perioperative antibiotic prophylaxis were used routinely. To acquire the presented data, all medical reports and operation protocols were studied and postoperative complications were evaluated regarding the Clavien–Dindo classification for surgical complications [10].
Statistics
All statistical calculations were performed using IBM® SPSS® Statistics Version 22 (IBM Inc., Armonk, New York). Fisher´s exact test was used for nominal parameters and Mann–Whitney U test for nonparametric tests for ordinal or continuous parameters. Logistic regression models were used for multivariate analysis. A p value of less than 0.05 was considered statistically significant.
Results
TN was performed in 195 patients, comprising of 119 (61%) men and 76 (39%) women with a median age of 51.4 years and a median transplant survival of 64 months. Patient characteristics are presented in Table 1. In 117 patients (60%), intracapsular surgical approach was used, whereas extracapsular technique was used in 36 patients (18.5%). Complications were detected in 99 patients (50.8%), of which 25 (12.8%) needed intervention under general anesthesia.
Looking on indications (Table 2) for TN in our cohort, graft intolerance syndrome most often was the underlying cause for TN in 52 patients (26.7%), followed by acute rejection in 36 (18.5%) cases, acute infection in 30 (15.4%) patients and other reasons to stop immunosuppression in 26 (13.3%) patients. More rare indications were vascular complications in 16 patients (8.2%) or malignancies in the allograft in 6 (3.1%) cases. Also, 21 (10.7) patients underwent TN for other reasons. In eight patients (4.1%), the indication for TN retrospectively could not be determined.
Next, we wanted to look for possible differences depending on whether intracapsular or extracapsular surgical approach was used. Descriptive statistics on all parameters examined are shown in Table 3. Significant differences were found when indication for TN was an acute vascular complication. Here, significantly more often an extracapsular surgical approach was used in 11 (30.6%) patients compared to 3 (2.6%) patients with intracapsular surgical approach (p > 0.001). In line with this finding, an extracapsular surgical approach was used significantly more often in earlier transplant loss, than intracapsular surgery (50 months vs. 67 months, respectively, p = 0.003). Interestingly, we found a difference in the rate of complications grade IIIb or higher according to Clavien–Dindo classification for surgical complications [10], indicating a higher complication rate in extracapsular 8 (22.9%) compared to intracapsular 10 (8.5%) surgical approach (p = 0.034%).
In our collective 25 complications grade IIIb or higher occurred, consisting of bleeding complications in 8 cases, wound dehiscence in 3 cases, urinoma in 2 cases, thrombosis of the renal vein, sigma perforation and dialysis shunt thrombosis. In nine cases of grade IV and V complications, one patient suffered from myocardial infarction, all other eight patients form septic multiple organ dysfunctions. To further investigate these findings, we looked for other factors contributing to a higher complication rate. Thereby, we found that the indication of acute infection had significant more complications than other indications (44.8% vs. 7.5%, p > 0.0001). Next, we aimed to determine the factor each parameter contributed to a higher complication rate and therefore performed a multivariate logistic regression analysis, examining the parameters already identified and other possible factors as shown in Table 4. Here, the initial descriptive finding of the surgical approach as a risk factor for a higher complication rate could not be confirmed. However, acute infection as an indication for TN could be confirmed as one independent risk factor. With a hazard ratio (HR) of 12.3 (CI 2.2–67.7; p = 0.004), it seems to have a strong impact on the risk to suffer a higher grade complication.
Discussion
When it comes to deciding whether a non-functional kidney allograft should be removed, opinions and recommendations vary, since there is currently no prospective data on (a) risks for the patients from surgery itself, and (b) implications for future re-transplantation. The retrospectively analyzed cohort in this work, with 195 included patients, is one of the largest single center cohorts. Although the biggest limitation of this study is clearly its retrospective design, it adds value to the discussion since risks for complications and risk factors for those become clearer for everyday decision making. In previous publications risks for complications due to TN vary widely with rates as high as 80% [11]. However, most of those studies have rather small patient cohorts, and larger and more recent studies report severe complications (grade IIIb or higher) at around 10% [11, 12] –16% [13]. The present study shows overall complication rates of 50.8% and 12.8% for complications grade IIIb or higher according to Clavien–Dindo classification. Those results are in line with other published larger cohorts of TN [11,12,13].
Furthermore, we found that TN performed due to acute infection was an independent risk factor with a HR of 12.3. This finding confirms the observation that urgent TN, especially in septic patients, leads to higher morbidity, as reported by Secin et al. and others in, however, smaller patient cohorts [14, 15].
Besides the perioperative risk for the patients due the procedure itself, possible immunological effects with implications for further transplantations must be considered, and although this study did not investigate this subject, it plays an important role for the indication for surgery. A larger meta-analysis from 2021 investigated the impact of TN on immunization and re-transplantation. They found higher levels of PRA, higher risk for delayed graft function and primary non-function. However, this did not translate into worse 5-year graft survival and patient survival [8].
Taken together those risks, our approach for TN is rather strict and we do not perform TN without real indication. In the present study, we identified indications that are similar to most published recommendations for TN [13, 16]. However, since there still are advocates to remove every failed graft, we eagerly await the results of the first prospective multicenter study, comparing systematic TN with conventional care after kidney graft failure (DESYRE) [17].
Considering the higher risk for perioperative complications in non-elective circumstances, such as acute infection or acute rejection, if possible, stabilization with subsequent surgery might be a better option. To address this, we have started treating patients with cortisone pulse therapy (500 mg prednisolone) in case of acute rejection or calculated broad spectrum antibiotics in case of acute infections instead of emergency surgery whenever clinically justifiable. Whether these actions will reduce perioperative risks remain to be evaluated. In an elective setting, however, for patients suffering mainly from GIS, another treatment option might be percutaneous embolization of the failed allograft, that can be performed under local anesthesia. A recent meta-analysis showed lower morbidity compared to TN, but 20% of patients needed a post-embolization nephrectomy none the less [18]. Considering other surgical techniques, there are few small case series of laparoscopic or robotic assisted TN [19,20,21]. With heterogenous results on operating time, mean hospital stay is about 4 days and no major complications are reported yet [19, 21]. However, so far, this technique has only been used in highly selected patients and there are no studies comparing laparoscopic to open techniques. Further larger studies are needed to answer whether this approach will be a better option than open surgery.
Data availability
The data that support the findings of this study are available on request from the corresponding author.
Abbreviations
- CI:
-
Confidence interval
- EPO:
-
Erythropoetin
- GIS:
-
Graft intolerance syndrome
- HR:
-
Hazard ratio
- PRA:
-
Panel reacting antibodies
- TF:
-
Transplant failure
- TN:
-
Transplant nephrectomy
References
Callaghan CJ, Bradley JA (2006) Current status of renal transplantation. Methods Mol Biol 333:1–28. https://doi.org/10.1385/1-59745-049-9:1
Gondos A, Dohler B, Brenner H, Opelz G (2013) Kidney graft survival in Europe and the United States: strikingly different long-term outcomes. Transplantation 95:267–274. https://doi.org/10.1097/TP.0b013e3182708ea8
FauChuang LA, P, Chuang P (2005) The management of the failed renal allograft: an enigma with potential consequences. Semin Dial 18:185–187. https://doi.org/10.1111/j.1525-139x.2005.18305.x
Lopez-Gomez JM, Perez-Flores I, Jofre R, Carretero D, Rodriguez-Benitez P, Villaverde M, Perez-Garcia R, Nassar GM, Niembro E, Ayus JC (2004) Presence of a failed kidney transplant in patients who are on hemodialysis is associated with chronic inflammatory state and erythropoietin resistance. J Am Soc Nephrol 15:2494–2501. https://doi.org/10.1097/01.ASN.0000137879.97445.6E
Vlachopanos G, El Kossi M, Aziz D, Halawa A (2022) Association of nephrectomy of the failed renal allograft with outcome of the future transplant: a systematic review. Exp Clin Transplant 20:1–11. https://doi.org/10.6002/ect.2021.0133
Del Bello A, Congy-Jolivet N, Sallusto F, Guilbeau-Frugier C, Cardeau-Desangles I, Fort M, Esposito L, Guitard J, Cointault O, Lavayssiere L et al (2012) Donor-specific antibodies after ceasing immunosuppressive therapy, with or without an allograft nephrectomy. Clin J Am Soc Nephrol 7:1310–1319. https://doi.org/10.2215/CJN.00260112
Khakhar AK, Shahinian VB, House AA, Muirhead N, Hollomby DJ, Leckie SH, McAlister VC, Chin JL, Jevnikar AM, Luke PP (2003) The impact of allograft nephrectomy on percent panel reactive antibody and clinical outcome. Transplant Proc 35:862–863. https://doi.org/10.1016/s0041-1345(02)04031-9
Gavriilidis P, O’Callaghan JM, Hunter J, Fernando T, Imray C, Roy D (2021) Allograft nephrectomy versus nonallograft nephrectomy after failed renal transplantation: a systematic review by updated meta-analysis. Transpl Int 34:1374–1385. https://doi.org/10.1111/tri.13901
Touma NJ, Sener A, Caumartin Y, Warren J, Nguan CY, Luke PP (2011) Extracapsular versus intracapsular allograft nephrectomy: impact on allosensitization and surgical outcomes. Can Urol Assoc J 5:49–52. https://doi.org/10.5489/cuaj.10016
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae
Alberts VP, Minnee RC, Bemelman FJ, van Donselaar-van der Pant KA, Idu MM, (2013) Transplant nephrectomy: what are the surgical risks? Ann Transplant 18:174–181
Mazzucchi E, Nahas WC, Antonopoulos IM, Piovesan AC, Ianhez LE, Arap S (2003) Surgical complications of graft nephrectomy in the modern transplant era. J Urol 170:734–737. https://doi.org/10.1097/01.ju.0000080566.42381.94
Chowaniec Y, Luyckx F, Karam G, Glemain P, Dantal J, Rigaud J, Branchereau JA-O (2018) Transplant nephrectomy after graft failure: is it so risky? Impact on morbidity, mortality and alloimmunization. Int Urol Nephrol 50:1787–1793. https://doi.org/10.1007/s11255-018-1960-4
Secin FP, Rovegno AR, del Rosario BM, Marrugat RE, Davalos Michel M, Fernandez H (2003) Cumulative incidence, indications, morbidity and mortality of transplant nephrectomy and the most appropriate time for graft removal: only nonfunctioning transplants that cause intractable complications should be excised. J Urol 169:1242–1246. https://doi.org/10.1097/01.ju.0000050658.94353.24
Akoh JA (2011) Transplant nephrectomy. World J Transplant 1:4–12. https://doi.org/10.5500/wjt.v1.i1.4
Leal RA-O, Pardinhas C, Martinho A, Sá Ho Auid O, Figueiredo A, Alves RA-O (2022) Challenges in the management of the patient with a failing kidney graft: a narrative review. J Clin Med 11:6108. https://doi.org/10.3390/jcm11206108
ClinicalTrials.gov (2022) Systematic transplantectomy versus conventional care after kidney graft failure. https://clinicaltrials.gov/ct2/show/NCT01817504. Accessed on 23 April 2023
Takase HM, Contti MM, Nga HS, Bravin AM, Valiatti MF, El-Dib RP, Modelli de Andrade LG (2018) Nephrectomy versus embolization of non-functioning renal graft: a systematic review with a proportional meta-analysis. Ann Transplant 23:207–217
McCabe M, Osinski T, Kashyap R, Taylor J, Schuler N, Shepard L, Ghazi A, Helbig K, Dokus MK, Nair A, Pineda-Solis K, Orloff M, Wu G (2023) Robotic assisted transplant nephrectomy: case series and training model for improving adoption. JSLS. https://doi.org/10.4293/JSLS.2022.00079
Mulloy MR, Tan M, Wolf JH, D’Annunzio SH, Pollinger HS (2014) Robotic trans-abdominal transplant nephrectomy for a failed renal allograft. Am J Transplant 14(12):2883–2886. https://doi.org/10.1111/ajt.12972
Paulo M, Silva RA, Silva MF, Dantas JH, Paiva RTM, Britto CA (2018) Laparoscopic transplant nephrectomy for failed renal allograft. Transplantation 102:538. https://doi.org/10.1097/01.tp.0000543387.59159.2f
Funding
Open Access funding enabled and organized by Projekt DEAL.
Author information
Authors and Affiliations
Contributions
J Mang: data collection, data analysis, manuscript writing. J Haag: data collection, data analysis. L Liefeldt: data collection, manuscript editing. K Budde: manuscript editing. R Peters: data collection, manuscript editing. M Schulz: data analysis. S Weinberger: manuscript editing. S Hofbauer: data collection. J Dagnæs-Hansen: manuscript editing. A Maxeiner: data collection. B Ralla: data collection, manuscript editing. F Friedersdorff: project development, manuscript editing.
Corresponding author
Ethics declarations
Conflict of interest
Authors disclose, that there are no interests that are directly or indirectly related to the work submitted for publication.
Ethics approval
This research study was conducted retrospectively from data obtained for clinical purposes. It was performed according to the standards and approval from the institutional ethics committee. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Mang, J., Haag, J., Liefeldt, L. et al. Transplant nephrectomy: indication, surgical approach and complications—experiences from a single transplantation center. World J Urol 42, 120 (2024). https://doi.org/10.1007/s00345-024-04884-8
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s00345-024-04884-8