How Should We Manage Renal Transplant Patients with Failed Allografts Who Return to Dialysis?

Patients with failing renal allografts often progress to end-stage renal disease, unlike transplant-naive chronic kidney disease patients, in an accelerated and unpredictable manner. The variability of this population renders decisions regarding placement of permanent dialysis access more difficult. Since patients with failed allografts who return to dialysis experience higher rates of morbidity and mortality, recognition and optimization of factors that will improve survival outcomes and quality of life are tantamount to longer term success. We provide guidelines on several topics such as immunosuppression withdrawal and determination of nephrectomy need versus retaining the allograft based on the current literature and our copious single-center experience.