When kidneys fail again: management of kidney allograft failure in children

Many children who receive a kidney transplant will require more than one transplant during their lifetime. When the first graft fails, decisions made during this transition may affect not only the return to kidney replacement therapy but also the chances of receiving a subsequent transplant. In particular, withdrawal of immunosuppression, development of HLA sensitization, graft intolerance, and the decision to remove or retain the failed allograft require careful consideration. In this Mini Review, we examine the epidemiology and causes of kidney allograft failure in children and discuss the practical challenges that follow graft failure. Evidence specific to children is scarce, especially regarding how and when immunosuppression should be withdrawn. Current data favor early preparation for retransplantation and avoidance of unnecessary sensitization. An asymptomatic failed allograft can generally remain in situ , whereas nephrectomy is reserved for specific indications. Despite greater sensitization after a first transplant, second kidney transplants in children can achieve good graft survival. Prospective pediatric studies are needed to determine how immunosuppression and the failed allograft should best be managed while preserving access to retransplantation.