The number of patients returning to dialysis after kidney graft failure is increasing, because of limited survival of the kidney graft, increased number of kidney transplantations and decreased access to a new transplantation due to immunisation [1] .

According to several recent studies, kidney graft failure is the fourth leading cause to dialysis initiation [2] [3] .

This transition period from renal transplantation to dialysis is associated with high high risk of complications. Indeed, patients on dialysis after kidney graft failure are reported to have a higher mortality rate than those who retain a functional graft [1] .

This is explained by an inflammatory state due to the allograft, leading to anemia via erythropoietin resistance and hypoalbuminemia.

In addition, maintaining immunosuppressive therapy after return to dialysis in order to preserve residual kidney graft function and prevent graft necrosis increases the risk of infectionandtumors [4] .

Psychological difficulties have also been reported in these patients following the change of care teams, but especially due to the end of autonomy related to renal transplantation [5] .

This finding should draw attention to the importance of monitoring these patients during this period.

Much has been written regarding the risks incurred by this population. However, no clearly defined management strategy is available: the timing of dialysis initiation is not well defined, the management of immunosuppressive drugs is not standardised and indication for detransplantation remains controversial.

In the light of the data, we undertook a study of patients returning to dialysis after kidney graft failure in our center.

We describe the clinical and paraclinical characteristics, therapeutic management and evolutionary profile of those patients.

This is a retrospective, descriptive, monocentric study conducted in the Nephrology-Dialysis-Transplantation Department of IbnSina University Hospital in Rabat.

The study period is spread over 23 years, from January 1998 to December 2021.

We included all kidney transplant patients followed in our unit who presented a kidney graft dysfunction and returned to dialysis.

We excluded from this study kidney transplant patients with a follow-up after return to dialysis less than 1 year.

Variables and definitions:

We analyzed the demographic, clinical, paraclinical, therapeutic and evolutionary data of these patients.

Data were collected from medical files in the renal transplant unit, and the analysis of the data concerned 3 periods:

For which the analysis was essentially descriptive.

This period was analyzed in terms of the patients’ age, their comorbidities, their clinical examination and the results of biological tests. We also recorded the modality and the circumstances of the return to dialysis as well as the need to place a central venous catheter.

We noted the dosage of the immunosuppressive treatment, i.e. anti-metabolite, anticalcineurin and corticosteroids at Day 0, day of the return to dialysis, at 1 month, 3 months, 6 months and 1 year.

We defined early cessation of immunosuppressive therapy as cessation of anti-metabolite and anticalcineurin before 120 days after return to dialysis.

We also reported infectious episodes, the hospitalisation requirement, the occurrence of rejection and the need for detransplantation.

We judged patient outcomes based on the occurrence of infection, graft intolerance syndrome, need for detransplantation, detection of HLA antibodies, and patient survival at 1 year.

The statistical analysis was carried out using JAMOVI software version 2.3.21.0.

Quantitative variables are expressed as means and standard deviation, median and interquartile range, and qualitative variables as number and percentage.

The data are compared using the Chi-2 test or Fisher’s exact test.

Among 166 kidney transplant patients, we identified 20 patients who returned to dialysis during the inclusion period, corresponding to a prevalence of 12%.

The mean age of our patients at the time of return to dialysis was 38.7 ± 11.9 years, with a sex ratio M/F of 2.3.

1) Period of dialysis before renal transplantation

Initial nephropathy was glomerular in 3 patients: 1 case of membranous nephropathy and 2 cases with IgA nephropathy. Nephroangiosclerosis, Alport syndrome and polycystic kidney disease were noted in 1 case each.

Chronic tubulointerstitial nephritis was involved in 3 patients. While the initial nephropathy remained undetermined in 11 patients.

The most frequent dialysis modality before renal transplantation was haemodialysis for 19 patients with a mean dialysis duration of 34.5 ± 29.5 months.

2) Period of renal transplantation:

Three patients received a kidney from a brain-dead donor (BDE) and 17 patients from a living donor, with a median kidney graft survival time of 85.5 months [42 - 186].

The causes of kidney graft dysfunction are listed in Table 1 .

3) Period of return to dialysis after renal transplantation:

The clinical characteristics of patients after return to dialysis are summarised in Table 1 and the biological data in Table 2 .

At the time of return to dialysis, 14 patients (70%) remained hypertensive with more than 3 antihypertensive treatments, 2 patients had heart disease (10%) and only 1 patient developed a new-onset diabetes after transplant (NODAT) (5%). Chronic smoking was reported in only one patient (5%).

The average BMI of our patients was 22 kg/m² ± 3, with extremes ranging from 18.3 to 26 kg/m². In addition, 4 patients presented psychological disorders requiring psychiatric follow-up (20%).

Biologically, an inflammatory syndrome was found in the majority of our patients with a median C-reactive protein (CRP) of 15.5 [3.8 - 27].

The initiation of dialysis was urgent in 10 patients (50%), with a low average GFR of 5.1 ml/min/1.73m². This dialysis was carried out using a central venous catheter in 7 patients (35%), one of whom was tunnelled, while 8 patients had a previously prepared AVF. Once the emergency was over and after education sessions, 15 patients opted for HD and 5 for PD.

Regarding the management of immunosuppressive therapy, we kept oral corticosteroid therapy at low dose (5 mg/d) for the first year. The antiproliferative agent is reduced by 50% per month until discontinuation and the anticalcineurin is reduced by 1mg every two weeks for tacrolimus and 25 mg every two weeks for ciclosporin until discontinuation.

Thus, weaning from mycophenolatemofetil (MMF) and anticalcineurins is achieved progressively over a period of 3 months and 5 months respectively. Three patients were allowed to stop immunosuppressive treatment early without clinical consequences on the kidney graft ( Figure 1 ).

During the first year of follow up, 13 patients (65%) required one or two hospitalisations, with an average duration of hospitalisation of 15 days. Eight patients were hospitalised for infections: 4 cases of tuberculosis, 3 case of dialysis catheter related infection and 1 case of peritonitis in PD. The evolution was favorable for all patients after appropriate antibiotic therapy.

^aExpressed as mean ± standard deviation, ^bExpressed as number (percentage), ^cExpressed as median [interquartile range].

^aExpressed as mean ± standard deviation, ^bExpressed as median [interquartiles].

After a mean follow-up of 22 months, 8 patients presented a kidney graft intolerance syndrome, 5 of them during the first year.

The clinical symptomatology was suggestive of kidney graft sensitivity in 8 cases, associated with haematuria in 6 cases and resistant hypertension in 2 cases. All patients had an elevated CRP, averaging 92.9 ± 76.6 mg/l with extremes between 25 and 207 mg/l. Doppler ultrasound of the kidney graft performed in all patients showed infiltration of the graft associated with foci of pyelonephritis in 2 patients.

Increasing the dose of steroids from 5 to 20 mg improved the clinical signs in 2 patients, while 6 patients required detransplantation. The histological examination of the graft showed foci of necrosis in 5 patients and pyonephrosis in one patient.

The evolution was favorable for all patients after detransplantation with a regression of clinical symptoms, normalization of blood pressure and resolution of the biological inflammatory syndrome.

Despite the deteriorated condition of the patients at the time of initiation of dialysis, only one death occurred after 16 months following a covid-19 infection.

In statistical analysis, the comparison between the early weaned group of immunosuppresive therapy (<120 days) and the late weaned group (>120 days) showed a significant association between the prolongation of immunosuppressive therapy beyond 120 days and the occurrence of infection (p < 0.05) ( Table 3 ).

In terms of psychological care, our patients experienced psychological difficulties during the period of transition. The beginning of dialysis marks a period of adaptation, as the patient’s rhythm of life is affected by the frequency of dialysis sessions.

IS: Immunosuppressive therapy; HLA: Human leukocyte antigen.

The majority of patients felt nervous, stressed, anxious, had no desire for anything, and experienced mood swings. Some of them were restless and had sleeping difficulties.

Four patients were depressed, refused dialysis and required psychiatric follow-up.

These psychological difficulties can be attributed to changes in medical teams, from the transplant doctor to the dialysis doctor, but mostly due to the loss of autonomy provided by the kidney transplant.

The transition from kidney graft to dialysis is associated with high morbidity and mortality [28] - [30] [38] . However, there are no practical recommendations for the management of these patients. We believe that adequate preparation for dialysis initiation, early management of comorbidities and creation of a vascular access could improve outcomes and reduce risks in this population.