Transplant Nephrectomy

In my experience, it’s unusual to perform a transplant nephrectomy in a patient who has returned to dialysis in the absence of a ‘hard’ indication such as macroscopic hematuria or severe symptoms suggestive of rejection or infarction. There have been several occasions where I’ve considered transplant nephrectomy for failure to thrive or refractory anemia, but persuading a surgeon that this is necessary can be a challenge. If you’ve ever been in a similar situation, this paper may interest you.

The authors examined all transplant recipients who returned to dialysis over a ten-year period, using the US Renal Data System. This amounted to approx 11,000 people, a third of whom underwent allograft nephrectomy. They found allograft nephrectomy to be independently associated with improved survival; specifically, there was a 32% lower relative risk for all-cause death after adjusting for many factors, including socioeconomic status, comorbidity, donor characteristics and identifiable conditions associated with requirement for allograft nephrectomy. The authors also excluded patients whose transplant lasted less than 3 months, as they would been likely to have an absolute indication for nephrectomy.

Being a retrospective, observational study, one needs to take the results with a pinch of salt, given the possibility of residual confounding and treatment selection bias. Also, there were some important differences in the baseline characteristics between the groups, e.g. patients who received nephrectomy were more likely to be younger, have a higher serum creatinine concentration and a higher serum albumin, suggesting they were better nourished.

This topic strikes me as a relatively straightforward subject for a randomized controlled trial. As it stands, these observations would embolden me to push a little harder for a transplant nephrectomy in someone with a ‘soft’ indication, in the knowledge that it does not appear harmful, and may in fact reduce mortality. And in the dialysis population, that’s no mean feat.