title: Nephrectomy for the failed renal allograft in children: predictors and outcomes.
abstract: BACKGROUND
  There are no guidelines for the removal of a failed renal allograft, and its impact on subsequent dialysis and retransplantation has not yet been described.
  
  
  METHODS
  We performed a 10-year review of allograft failure to study the factors that determined an outcome of transplant nephrectomy and choice of subsequent renal replacement therapy in children with or without nephrectomy.
  
  
  RESULTS
  A total of 34 children developed graft failure over the 10-year study period, of whom 18 (53 %) required transplant nephrectomy. The median graft survival was 1.1 (range 0.2-10.6) versus 7.5 (1.5-15.0) years in the nephrectomy and non-nephrectomy groups, respectively (p = 0.011). Children with graft failure within 1 year of transplantation were four-fold more likely to require transplant nephrectomy than those with graft failure after 1 year (p = 0.04). Renal biopsy performed at ≤ 8 weeks prior to graft loss showed Banff grade II acute rejection in 13 of the 18 children who required subsequent nephrectomy versus three of the 13 children who did not need nephrectomy (p = 0.01). Inflammation (fever, graft tenderness and raised C-reactive protein (CRP) in the 2 weeks preceding graft failure) was seen in 66 % of nephrectomized children, but not in any in the non-nephrectomy group (p = 0.0003 for CRP between groups). Banff II rejection, an inflammatory response and the time post-transplantation significantly and independently predicted the outcome of nephrectomy (p = 0.008, R (2) = 67 %). Human leukocyte antigen (HLA) antibody levels after graft failure were higher in the nephrectomy group (p = 0.0003), but there was no difference between groups in terms of the presence or class of donor-specific antibodies. Of the children with graft failure, 82 % required dialysis (61 % hemodialysis) and 35 % have to date been successfully retransplanted.
  
  
  CONCLUSIONS
  Children with Banff II rejection, an inflammatory response and early graft loss are more likely to require transplant nephrectomy. Nephrectomy may be associated with higher circulating HLA antibody levels.
authors.affiliation: Renal Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Minson
authors.forename: Marina
authors.initials: M
authors.lastname: Muñoz
authors.forename: Inés
authors.initials: I
authors.lastname: Vergara
authors.forename: Martin
authors.initials: M
authors.lastname: Mraz
authors.forename: Robert
authors.initials: R
authors.lastname: Vaughan
authors.forename: Lesley
authors.initials: L
authors.lastname: Rees
authors.forename: Jonathon
authors.initials: J
authors.lastname: Olsburgh
authors.forename: Francis
authors.initials: F
authors.lastname: Calder
authors.forename: Rukshana
authors.initials: R
authors.lastname: Shroff
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000367:Age Factors; D015415:Biomarkers / Q000097:blood; D001706:Biopsy; D002097:C-Reactive Protein / Q000378:metabolism; D002648:Child; D002675:Child, Preschool; D005260:Female; D006084:Graft Rejection / Q000097:blood / Q000276:immunology / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D006085:Graft Survival; D006680:HLA Antigens / Q000097:blood / Q000276:immunology; D006801:Humans; D007223:Infant; D018836:Inflammation Mediators / Q000097:blood; D007518:Isoantibodies / Q000097:blood; D053208:Kaplan-Meier Estimate; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D015999:Multivariate Analysis; D009392:Nephrectomy / Q000009:adverse effects; D006435:Renal Dialysis / Q000009:adverse effects; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D015854:Up-Regulation
chemical_list: D015415:Biomarkers; D006680:HLA Antigens; D018836:Inflammation Mediators; D007518:Isoantibodies; D002097:C-Reactive Protein