Allograft nephrectomy: a systematic review of immunological consequences and management of immunosuppressants

Abstract

Allograft nephrectomy (AN) is a serious complication of kidney transplantation. Beyond surgical morbidity, AN has important immunological implications. We performed a systematic review to synthesize current evidence on the immunological impact of AN and post-allograft failure immunosuppressive strategies. A systematic review was conducted according to PRISMA guidelines. PubMed/Medline® was searched for studies published from 01/2000 to 03/2026 on transplantectomy indications and surgical techniques. Eligible designs included meta-analyses, randomized trials, and prospective or retrospective studies evaluating the immunological impact of AN and/or immunosuppression management before, during, or after graft removal in adult or pediatric kidney transplant recipients returning to dialysis. Consistent evidence indicates that immunosuppression withdrawal is the principal driver of allosensitization after graft failure. Multiple studies demonstrated marked increases in anti-HLA antibodies following the cessation of immunosuppression, regardless of nephrectomy status. When AN was performed under maintained immunosuppression, its independent effect on sensitization and retransplant outcomes appeared limited. Meta-analyses showed comparable survival after retransplantation, although higher PRA levels, delayed graft function, and acute rejection were more frequent in patients with prior nephrectomy. Allosensitization after graft failure is primarily driven by immunosuppression withdrawal/reduction rather than AN itself. Individualized immunosuppressive management balancing immunological and infectious risks is essential.

Introduction

Kidney transplantation is the best treatment for patients suffering from end-stage kidney disease, as it provides superior survival, quality of life, and cost-effectiveness while having a lower environmental burden than long-term dialysis [1–3]. Advances in surgical techniques, donor selection, peri-operative management, and immunosuppressive therapies have improved short- and long-term graft outcomes [4, 5]. Nevertheless, graft loss continues to occur in a substantial proportion of transplant recipients, and management of the failed renal allograft represents a major clinical challenge. In this setting, transplant nephrectomy (also referred as “transplantectomy”), defined as the surgical removal of a renal allograft, constitutes a serious complication of kidney transplantation with important clinical, immunological, and prognostic implications.

Transplant nephrectomy may be required at different timepoints after transplantation and for a wide spectrum of indications. In the immediate postoperative period, nephrectomy is most commonly performed due to surgical complications, including arterial or venous thrombosis [6, 7]. At later stages, transplant nephrectomy is frequently indicated after return to dialysis following chronic graft failure, particularly in patients who develop symptomatic rejections (so-called “graft intolerance syndrome,” a condition characterized by graft-related pain, fever, hematuria, anemia, and systemic inflammation reflecting the ongoing immune activation) [8–10], and severe infectious or cancer complications of the graft (such as recurrent pyelonephritis or cancer, depending on the failed graft). More rarely, transplant nephrectomy may be required despite preserved graft function, usually as a consequence of complex vascular, neoplastic, or ureteral complications that are not (or failed to be) amenable to conservative management.

Beyond its indication, transplant nephrectomy is associated with significant morbidity [11]. Infectious complications are among the most frequent and severe adverse events following nephrectomy [12]. Patients undergoing allograft removal often present with multiple predisposing factors, including residual immunosuppression, chronic inflammation related to the failed graft, and malnutrition [13]. Surgical site infections, intra-abdominal abscesses, and sepsis are not uncommon and contribute substantially to early morbidity and mortality [12]. Cardiovascular complications represent another critical concern. Several observational studies have reported increased cardiovascular morbidity and mortality in patients after transplant nephrectomy, although disentangling the independent effects of surgery, graft loss, and dialysis resumption remains challenging [11]. One of the most consequential long-term effects of graft failure and transplant nephrectomy is their role in allosensitization. Removal of the renal allograft has been associated with an increased production of donor specific and non-specific anti-human leukocyte antigen (HLA) antibodies. Several factors, such as the timing of nephrectomy, the duration of graft survival, and the strategy used for immunosuppression withdrawal, have been suspected to influence allosensitization post nephrectomy [6, 14–16]. The immunological consequences of transplant nephrectomy have fueled ongoing debate regarding the optimal management of failed renal allografts. Strategies such as maintaining low-dose immunosuppression have been proposed to mitigate sensitization, but robust evidence remains limited [17, 18]. Furthermore, the balance between reducing immunological risk and minimizing infectious and cardiovascular complications is of paramount importance.

In this systematic review, we aimed to synthesize the evidence regarding the impact of an allograft nephrectomy and the management of immunosuppression.

Methods

This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [19]. The protocol for this systematic review was prospectively registered in PROSPERO (International Prospective Register of Systematic Reviews; CRD420251040524).

Evidence acquisition

A systematic literature search was performed in PubMed/MEDLINE® to identify reports (in French or English) on allograft nephrectomy, published between January 2000 and March 2026, in accordance with PRISMA criteria. The full search strategy is provided in Supplementary Table S1. Study selection was based on the PICOS criteria: Population (P): patients with graft failure after a first kidney transplantation, regardless of severity or age; Intervention (I): allograft transplantectomy (transplant nephrectomy), encompassing different surgical techniques; Comparator (C): other surgical approaches, immunosuppression management strategies, dialysis, or embolization; Outcomes (O): morbidity and mortality (including cardiovascular and immunological impact), adverse events (myocardial infarction, congestive heart failure, sepsis, etc.), time or access to retransplantation, anatomical feasibility for retransplantation, quality of life, and acceptability; and Study design (S): meta-analyses, randomized controlled trials, non-randomized prospective studies, or retrospective studies. Bibliographic data were complemented by literature monitoring (up to June 2024), consultation of international society websites (European Association of Urology, American Urological Association, British Transplantation Society, UK Kidney Association, and American Society of Transplantation), a search for systematic reviews in the Cochrane Library database, and suggestions from the working group. The search strategy was designed to address four predefined clinical questions: (1) the indications for kidney allograft transplantectomy and its optimal timing; (2) the immunological impact of transplantectomy and the management of immunosuppression before, during, and after the procedure; (3) surgical techniques for transplantectomy; and (4) alternatives to transplantectomy, including conservative management strategies. The present article reports the results of the literature selection and evidence synthesis related to question 2, focusing on immunological impact and management of immunosuppressants before, during, and after the allograft nephrectomy.

Eligibility criteria and study selection

Inclusion and exclusion criteria were predefined prior to the study. Only studies addressing the immunological impact and management of immunosuppressants before, during, and after the allograft nephrectomy were included. Publications deemed ineligible were (i) health economic studies, as they largely depend on country-specific healthcare systems; (ii) case reports, narrative reviews, editorials, letters, or commentaries; (iii) experimental animal or in vitro studies; (iv) studies focusing on laboratory technology aspects; (v) studies on clinical practice patterns; and (vi) out-of-scope studies (e.g., not kidney-specific, public health topics not specific to kidney transplantation, immunosuppressive therapy efficacy, transplantation technique, donor nephrectomy techniques in living donors, dialysis modality, retransplantation, or primary non-function related to cancer).

Study selection was initially performed by the methodologist (DK) based on these criteria after abstract screenings. The selection was independently validated by the steering committee (TC, AF, AG, TP, and ADB) and subsequently by the full working group. Full texts of selected publications were then reviewed. Following an initial data extraction by the steering committee, the final set of included studies was confirmed by the steering committee, and any disagreements were resolved through discussion with the working group.

Quality assessment

The methodological quality of the included studies was evaluated using validated critical appraisal tools appropriate to each study design (e.g., randomized, prospective non-randomized, or retrospective studies), combining criteria derived from the Haute Autorité de Santé (HAS) evidence appraisal framework [20], the STARD (Standards for Reporting Diagnostic Accuracy Studies) checklist [21], and the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool [22], when applicable. These assessments considered the clinical relevance of the study objectives, representativeness of the selected patients, appropriateness of inclusion and exclusion criteria, relevance of the recruitment period, independence between cohorts, blinding of outcome assessment, identification and adjustment for potential confounding factors, clinical relevance of the compared methods, validity and definition of outcomes, as well as funding sources and conflicts of interest. The level of evidence (LoE) was attributed to each study after taking into account the protocol design and the risk of bias (Supplementary Table S2). The classification of conclusions by LoE (LoE1 is the highest; LoE4 the lowest) was based on the grid proposed by HAS [20]. The risk of bias was assessed independently by two reviewers, and discrepancies were solved by consensus. Randomized and prospective non-randomized studies were prioritized in the analysis, and retrospective studies were included but interpreted with caution. This work was then reviewed by 33 independent experts from all medical and surgical specialties involved in the management of patients with renal graft failure (10 urologists, 4 nephrologists, 4 pediatric nephrologists, 3 immunologists, 3 vascular surgeons, 2 pediatric urologists, 1 pediatric surgeon, 1 infectiologist, and 6 patient representatives). A summary of the methodological analysis of included studies is presented in Supplementary Table S2.

Results

Study selection is detailed in the PRISMA flow diagram (Figure 1). In total, 2,236 records were screened for eligibility and 100 were selected. After full-text review, additional literature checking, and suggestions from the working group, 29 studies were ultimately included for analysis to address the question on “immunological impact and management of immunosuppressants before, during, and after an allograft nephrectomy”: 2 systematic reviews/meta-analyses [23, 24], 9 retrospective comparative studies [15, 25–31], and 18 retrospective observational studies [6, 11, 14, 16, 32–45] summarized in the Table 1.

FIGURE 1

The role of removing the failed graft in the development of allosensitization

The failed graft constitutes a reservoir of donor antigens. In the absence of immunosuppression, ongoing antigen presentation by infiltrating recipient antigen-presenting cells (mainly after late allograft failure) or resident donor-derived cells (in case of early allograft failure) may promote recipient immune activation, leading to antibody formation. The inflammatory milieu surrounding the failing graft may amplify antigen presentation and costimulatory signaling [46–48].

Histopathological data support the role of inflammation. Goral et al [6] reported extensive inflammatory infiltrates in explanted grafts, including plasma cells and tertiary lymphoid structures, which may sustain local antibody production. In such contexts, graft nephrectomy may exacerbate antigen release, immune activation, and de novo DSA formation [14, 33].

It was also suggested that the failed graft could adsorb (or regulate) anti-HLA antibody specificities and prevent detection of some anti-HLA antibodies (the so-called “sponge effect”) despite the use of highly sensitive tests [43]. According to this hypothesis, removal of the antigen source could lead to an apparent increase in circulating anti-donor antibodies, as antibodies previously sequestered within the allograft become detectable following graft removal [16, 36]. However, this hypothesis has not been substantiated by direct experimental evidence and is instead supported by indirect clinical observations, including the rapid development of donor-specific antibodies following allograft nephrectomy [16]. However, it should be noted that sera considered as pre-allograft nephrectomy were collected several weeks before the surgery, which could represent a major bias. Recent studies have demonstrated that this effect is probably limited. Indeed, Milongo and colleagues [49] investigated the presence of anti-HLA DSA in both the blood and nephrectomy eluates in 17 patients. They observed that all anti-HLA DSA detected in the nephrectomy eluates were also detected in blood at the time of nephrectomy [49].

Immunosuppression withdrawal (more than graft nephrectomy in itself) plays a key role in allosensitization after graft failure

While graft nephrectomy has long been considered a major driver of alloimmunization, accumulating evidence suggests that its immunological impact is largely mediated by the management of immunosuppressive therapy rather than by the surgical removal of the graft itself (Table 3). Several studies consistently demonstrated that cessation of immunosuppressive therapy after graft failure is associated with a rapid and marked increase in anti-HLA antibodies, preceding nephrectomy. In a retrospective comparison study involving 69 patients who returned to dialysis and stopped their immunosuppression, Del Bello and colleagues [28] showed that discontinuation of immunosuppression led to a sharp rise in anti-HLA antibodies detection, regardless of whether nephrectomy was subsequently performed (anti-HLA DSA detected in 52% patients without a history of nephrectomy and 81% in those with nephrectomy). Augustine et al [34] further reinforced this concept by demonstrating in a cohort of 119 patients who returned to dialysis that late sensitization after kidney transplant failure was independently associated with immunosuppression weaning, even in the absence of nephrectomy. Patients who discontinued calcineurin inhibitors and antiproliferative agents experienced a significant increase in panel reactive antibodies (PRA) (Median PRA rose from 0% before transplantation to 57% in class I and 63% in class II, 6–24 months post graft failure), indicating broad alloimmune activation. Similar findings were reported by Nimmo et al. [29], who showed that withdrawal of maintenance immunosuppression was the dominant factor influencing the calculated chance of future transplantation, with nephrectomy exerting only a secondary effect. They observed in 41 patients that immunization (expressed by calculated reaction frequency, cRF) rose from 13% pre-immunosuppression weaning to 62% post immunosuppression withdrawal. In the subgroup of 17 patients who underwent graft nephrectomy, the mean cRF rose similarly to others, from 31% pre-immunosuppression wean to 69%. Kosmoliaptsis and colleagues [45] observed that the development of anti-HLA antibodies after return to dialysis in patients listed for another transplantation was independent of graft nephrectomy but associated with waitlist time and maintenance on dual immunosuppression.

The higher allosensitization observed after graft nephrectomy in comparison with immunosuppression weaning only could be related to the surgical intervention in inflammatory conditions and to the high rate of blood transfusion required during or immediately after the surgery [28, 29, 43]. Lucisano et al [33] conducted a retrospective study evaluating the relative contributions of transplantectomy and immunosuppression management to allosensitization in 109 patients. They found that continued immunosuppression (with tacrolimus levels ≥3 ng/mL) was associated with lower rates of de novo anti-HLA antibody formation, irrespective of whether transplantectomy was performed. Schachtner et al [31] extended this concept by demonstrating that graft nephrectomy was associated not only with humoral sensitization but also with presensitization at the T-cell level. They investigated the donor-reactive T cell response by using an IFN-γ ELISPOT assay in a cohort of 111 patients who returned to dialysis (51 with a history of graft removal and 60 without). They observed increased frequencies of donor-reactive T cells responses and inferior outcomes after retransplantation in patients with a history of graft removal in comparison with patients without.

Graft nephrectomy in patients maintained on immunosuppression

Studies focusing on early graft nephrectomy (performed while immunosuppression is ongoing) highlight that sensitization could occur even if the graft nephrectomy is performed only a few minutes after the transplantation. Lenaers et al [35] reported an important (50% of patients) donor-specific alloimmunisation in 32 patients who lost their graft and underwent a nephrectomy during the first 4 months post transplantation. Similarly, Del Bello et al. [14] specifically examined early allograft nephrectomy (<3 months post transplantation) performed under immunosuppression and observed significant anti-HLA immunization (57% of patients after 9 months post nephrectomy). Similarly, when immunosuppression is maintained until nephrectomy in patients with late graft failure, allosensitization is frequent. In a retrospective study of 41 patients (17 with graft nephrectomy, all of whom were maintaining immunosuppression until the surgery), Nimmo and colleagues [29] found high allosensitization (the cRF rose from 31% pre-immunosuppression wean to 69% post-immunosuppression wean and 89% post-immunosuppression cessation). Similarly, Lachmann and colleagues [30] retrospectively compared the allosensitization rate in 28 patients who received a nephrectomy after immunosuppression discontinuation, in 14 patients who received a nephrectomy under immunosuppression (stopped immediately after), and 12 patients who stopped their immunosuppression without nephrectomy. They observed similar allosensitization rates (100% of patients after nephrectomy post immunosuppression withdrawal, 100% of patients after nephrectomy under immunosuppression, and 92% of patients who underwent an immunosuppression only). Matignon and colleagues observed that immunosuppression tapering in the month after the nephrectomy had limited impact on the development of allosensitization, as well as the use of high doses of intravenous immunoglobulins [27]. This could be explained by the persistence of some donor tissue after nephrectomy (in vascular patches). Alloimmunisation could then occur in patients who stop their immunosuppression after the surgery due to these residues [28]. Freist and colleagues [15] observed a lower rate of DSA in patients who maintained a calcineurin inhibitor-based immunosuppression (30/52 (57.7%) vs. 52/67 (77.6%), p = 0.02), as well as a lower rate of non-DSA allo-sensitization (17% vs. 38%, p = 0.03) regardless of the need for an allograft nephrectomy.

As expected, the number of HLA mismatches is an important factor leading to allo-sensitization [28, 40, 45]. All mismatched loci contribute to allosensitization in a similar way [45].

Beyond the formation of anti-HLA DSA, a broad allosensitization is frequently observed after immunosuppression tapering/discontinuation. By using HLA matchmaker™ [28, 41] or recombinant single HLA allele–expressing cell lines [30], several authors demonstrated that a majority of these anti-HLA non-DSA antibodies were directed against donor’s epitopes at the molecular level.

Graft nephrectomy and impact of retransplantation

The impact of graft nephrectomy on subsequent retransplantation remains a matter of ongoing debate, as its clinical consequences are closely intertwined with alloimmunization and immunosuppression management. In a recent USRDS-based study, Achinger and colleagues observed that patients who underwent an allograft nephrectomy had higher chances of receiving a second transplant (subdistribution HR: 1.21, 95%CI[1.15–1.28, p < 0.001) [50]. When nephrectomy is performed under continued immunosuppression, its independent effect on retransplantation rates appeared limited (Table 2). In an initial meta-analysis of eight studies (1,008 patients), Wang and colleagues [51] did not observe a difference regarding the retransplant outcome (1 year graft survival: OR = 0.74; 95%IC [0.31–1.72]; p = 0.48, 1 year patient survival: OR = 1.60; 95%IC [0.57–4.46]; p = 0.37), acute rejection rate (OR = 1.30; 95%IC [0.89–1.91]; p = 0.17), post-operative complications (OR = 1.51; 95%IC [0.24–9.43]; p = 0.66), or graft function at 1 year (mean ponderate difference: -0.25; 95%IC [-0.52 à 0.03]). Nonetheless, patients with a history of graft nephrectomy present a prolonged time between dialysis and retransplantation (mean ponderate difference in months 11.23; 95%IC [2.47–19.99]; p = 0.01) and increased PRA of more than >10% (OR = 1.62; 95%IC [1.17–2.23]; p = 0.003). Another meta-analysis [13] that included 16 retrospective studies (2,256 patients) reported similar 5-year graft (HR = 1.11, 95%IC [0.89–1.38]; p = 0.37) and patient survival (HR = 0.70; 95%IC [0.45–1.10]; p = 0.12). Nonetheless, patients who underwent graft nephrectomy presented high PRA at retransplantation (%PRA: 39% vs. 35%; OR = 1.83; 95%IC [1.20–2.78]; p = 0.005), delayed graft function (39% vs. 30%; OR = 1.86; 95%IC [1.16–2.98]; p = 0.01), acute rejection (33% vs. 28%; OR = 1.70; 95%IC [1.31–2.22]; p = 0.001), and primary non-function (8% vs. 1.7%; OR = 3.41; 95%IC [1.31–8.89]; p = 0.001).

Collectively, these data suggest that graft nephrectomy in itself does not seem to have a detrimental effect on the outcomes of retransplantation.

Discussion

This systematic review on the immunological impact of AN and post-allograft failure immunosuppressive strategies has been conducted to inform the 2025 French guidelines on Allograft nephrectomy: Indications and surgical techniques [52].

The optimal management of immunosuppressive therapy following graft failure and nephrectomy remains controversial. Limiting the time between graft failure and retransplantation was recently underscored by Kainz and colleagues [53], and allosensitization is a major pitfall for retransplantation. Continuation of low-dose immunosuppression has been proposed to limit alloimmunization, particularly in patients who are candidates for retransplantation. Several studies recently highlighted lowered sensitization rates in [15] patients who maintained immunosuppression after graft failure compared with those who underwent rapid withdrawal [15, 54–56]. García Montemayor et al. [44] similarly observed increased development of donor-specific antibodies after reinitiation of dialysis when immunosuppression was discontinued. Leal and colleagues found that patients who maintained a calcineurin inhibitor after return to dialysis presented a lower rate of graft intolerance syndrome [57]. In a recent meta-analysis of 13 studies comprising 1,531 patients, Fragoso and collegues [54] found that maintaining immunosuppression more than 3 months (with at least two immunosuppressants) was associated with significantly lower odds of graft nephrectomy or embolization (OR:0.41, 95%CI[0.27.0.64]), with no significant impact on hospitalization rates, mortality, or retransplantation. These findings suggest that maintaining some degree of immune modulation may attenuate humoral responses, especially in patients with low baseline immunization. The ideal regimen to propose for patients in dialysis still remains to be identified. The importance of calcineurin inhibitors was highlighted, along with the functioning graft period. Lucisiano and colleagues [33] observed that patients who underwent a nephrectomy under tacrolimus and for whom the treatment was prolonged after the surgery presented a low rate of alloimmunization in comparison with patients who stopped their treatment at nephrectomy. The frequent need for blood transfusions following return to dialysis and in the perioperative period of allograft nephrectomy should also be considered as a potential contributor to HLA sensitization. Given the well-established association between transfusion exposure and alloantibody formation, this factor may partly account for the increase in sensitization observed after graft failure and provides an additional rationale for maintaining immunosuppression in candidates for retransplantation [58, 59]. However, the benefits of prolonged immunosuppression must be weighed against its risks. Woodside et al [26] reported increased rates of infection, fever, and hospitalization in patients who remained on immunosuppressive therapy after graft failure.

This finding supports a tailored approach in which immunosuppression continuation is considered in patients with a realistic prospect of retransplantation and low infectious risk. Dynamic approaches with minimization periods during infection complications and an increase of immunosuppression thereafter need to be assessed. Two studies are now open to assess the effect of controlled immunosuppression to reduce the risk of allosensitization after graft failure: in the PREVSENSI study (NCT06676696), the authors investigate the impact of maintaining a low dose of tacrolimus for 2 years in patients who returned to dialysis for late graft failure (>3 months post transplantation). A nationwide prospective study (TACITE) investigating the impact of maintaining a combination of immunosuppression containing tacrolimus is expected to start soon in France. Finally, a pilot study aiming to reduce allosensitization after an early allograft nephrectomy (RAIPONS study, NCT04779957) suggested that anti-IL6 receptor blockers infusion could limit allosensitization in this setting.

Decision-making regarding immunosuppression after return to dialysis should be individualized, integrating different parameters. The likelihood of retransplantation and baseline sensitization status should be assessed. Highly sensitized patients may derive limited benefit from continued immunosuppression, whereas non- or low sensitized patients may experience substantial harm from immunosuppression withdrawal. This is well illustrated by seminal studies in which PRA before and after transplant nephrectomy remain stable, while an increase was observed in low sensitized patients [36]. Since HLA mismatches burden strongly influences antibody development [45], this parameter should be taken into account. Moreover, the risk of infection should be assessed regularly in immunosuppressed dialysis patients.

Embolization of the failed graft has emerged as a possible less invasive alternative to transplantectomy, particularly in patients with graft intolerance syndrome. Although the immunological impact of embolization in comparison with graft nephrectomy remains to be assessed, we can suppose that embolization could reduce the risk of sensitization by reducing the need for blood transfusion, which is regularly needed after graft nephrectomy.

Conclusion

Our systematic review shows that the immunological impact of graft nephrectomy after kidney allograft failure is largely determined by the timing and manner of immunosuppression withdrawal and by the inflammatory context in which graft removal occurs. Evidence consistently shows that immunosuppression cessation is the principal driver of alloimmunization, often preceding and overshadowing the effects of nephrectomy. When performed while prolonged post-operative immunosuppression is maintained, graft nephrectomy appears to have a limited impact on allosensitization and retransplantation outcomes. Despite the inherent limitations of systematic reviews, we propose that management strategies should therefore prioritize individualized immunosuppression protocols to reduce the need for graft nephrectomy and limit subsequent allosensitization following graft failure.

References

• 1.

  WolfeRAAshbyVBMilfordELOjoAOEttengerREAgodoaLYet alComparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. New Engl J Med (1999) 341(23):1725–30. 10.1056/nejm199912023412303

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 2.

  ZhangYGerdthamUGRydellHLundgrenTJarlJ. Healthcare costs after kidney transplantation compared to dialysis based on propensity score methods and real world longitudinal register data from Sweden. Sci Rep (2023) 13(1):10730. 10.1038/s41598-023-37814-6

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 3.

  VanholderRAgarJBraksMGallegoDGerritsenKGFHarberMet alThe european green deal and nephrology: a call for action by the European kidney health alliance. Nephrol Dial Transpl (2023) 38(5):1080–8. 10.1093/ndt/gfac160

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 4.

  SextonDJO’KellyPWilliamsYPlantWDKeoganMKhalibKet alProgressive improvement in short-medium- and long-term graft survival in kidney transplantation patients in Ireland – a retrospective study. Transpl Int (2019) 32(9):974–84. 10.1111/tri.13470

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 5.

  GondosADohlerBBrennerHOpelzG. Kidney graft survival in Europe and the United States: strikingly different long-term outcomes. Transplantation (2013) 95(2):267–74. 10.1097/TP.0b013e3182708ea8

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 6.

  GoralSBrukampKTicehurstEHAbtPLBloomRDKearnsJet alTransplant nephrectomy: histologic findings—a single center study. Am J Nephrol (2014) 40(5):491–8. 10.1159/000369865

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 7.

  BessedeTDroupySHammoudiYBedretdinovaDDurrbachACharpentierBet alSurgical prevention and management of vascular complications of kidney transplantation. Transpl Int (2012) 25(9):994–1001. 10.1111/j.1432-2277.2012.01533.x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 8.

  McDonaldM. Allograft nephrectomy vs. no nephrectomy for failed renal transplants. Front Nephrology (2023) 3:1169181. 10.3389/fneph.2023.1169181

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 9.

  SinghPFeldRIColombeBWFarberJLHermanJHGulatiRet alSensitization, pathologic, and imaging findings comparing symptomatic and quiescent failed renal allografts. Clin Transpl (2014) 28(12):1424–32. 10.1111/ctr.12474

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 10.

  PessionULammersIHauserISchreckenbachTSchnitzbauerALangJet alTransplant nephrectomy: a comparative Study of timing and techniques in a single institution. Ann Transpl (2024) 29. 10.12659/AOT.942252

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 11.

  JohnstonORoseCLandsbergDGourlayWAGillJS. Nephrectomy after transplant failure: current practice and outcomes. Am J Transplant (2007) 7(8):1961–7. 10.1111/j.1600-6143.2007.01884.x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 12.

  AlbertsVPMinneeRCBemelmanFJvan Donselaar-van der PantKAMIIduMM. Transplant nephrectomy: what are the surgical risks?Ann Transpl (2013) 18(1):174–81. 10.12659/AOT.883887

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 13.

  GavriilidisPO’CallaghanJMHunterJFernandoTImrayCRoyD. Allograft nephrectomy versus nonallograft nephrectomy after failed renal transplantation: a systematic review by updated meta-analysis. Transpl Int (2021) 34(8):1374–85. 10.1111/TRI.13901

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 14.

  Del BelloACongyNSallustoFCardeau-DesanglesIFortMEspositoLet alAnti-human leukocyte antigen immunization after early allograft nephrectomy. Transplantation (2012) 93(9):936–41. 10.1097/TP.0b013e31824b3720

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 15.

  FreistMBertrandDBaillyELambertCRouzairePOLemalRet alManagement of immunosuppression after kidney transplant failure: effect on patient sensitization. Transpl Proc (2021) 53(3):962–9. 10.1016/J.TRANSPROCEED.2020.10.009

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 16.

  KnightMGTiongHYLiJPidwellDGoldfarbD. Transplant nephrectomy after allograft failure is associated with allosensitization. Urology (2011) 78(2):314–8. 10.1016/j.urology.2011.02.068

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 17.

  KnollGCampbellPChasseMFergussonDRamsayTKarnabiPet alImmunosuppressant medication use in patients with kidney allograft failure: a prospective multi-center Canadian cohort study. J Am Soc Nephrol (2022) 33(6):1182–92. 10.1681/ASN.2021121642

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 18.

  BadellIRBrayRAElbeinRChamiASEasleyKAPastanSOet alBelatacept in kidney transplant recipients with failed allografts for the prevention of humoral sensitization: a pilot randomized controlled trial. Transplantation (2021) 105(12):E395–E396. 10.1097/TP.0000000000003852

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 19.

  PageMJMcKenzieJEBossuytPMBoutronIHoffmannTCMulrowCDet alThe PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ (2021) 372:n71. 10.1136/bmj.n71

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 20.

  Haute autorité de Santé. Elaboration De Recommandations De Bonne Pratique (2020). Available online at: https://www.has-sante.fr/upload/docs/application/pdf/2020-02/reco363_gm_rbp_maj_janv_2020_cd_2020_01_22_v0.pdf (Accessed June 9, 2026).

  • Google Scholar
  • View reference in article

• 21.

  BossuytPMReitsmaJBBrunsDEGatsonisCAGlasziouPPIrwigLet alSTARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. BMJ (2015) 351:h5527. 10.1136/BMJ.H5527

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 22.

  WhitingPFRutjesAWSWestwoodMEMallettSDeeksJJReitsmaJBet alQUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med (2011) 155(8):529–36. 10.7326/0003-4819-155-8-201110180-00009

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 23.

  AndrewsPABurnappLManasDBradleyJADudleyC. Summary of the British transplantation society/renal association UK guidelines for living donor kidney transplantation. Transplantation (2012) 93(7):666–73. 10.1097/TP.0b013e318247a7b7

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 24.

  LubetzkyMTantisattamoEMolnarMZLentineKLBasuAParsonsRFet alThe failing kidney allograft: a review and recommendations for the care and management of a complex group of patients. Am J Transplant (2021) 21(9):2937–49. 10.1111/AJT.16717

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 25.

  SenerAKhakharAKNguanCYHouseAAJevnikarAMLukePP. Early but not late allograft nephrectomy reduces allosensitization after transplant failure. Can Urol Assoc J (2011) 5(6):E142–E147. 10.5489/cuaj.10032

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 26.

  WoodsideKJSchirmZWNoonKAHumlAMPadiyarASanchezEQet alFever, infection, and rejection after kidney transplant failure. Transplantation (2014) 97(6):648–53. 10.1097/01.TP.0000437558.75574.9C

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 27.

  MatignonMLeiblerCMoranneOSalomonLCharronDLangPet alAnti-HLA sensitization after kidney allograft nephrectomy: changes one year post-surgery and beneficial effect of intravenous immunoglobulin. Clin Transpl (2016) 30(6):731–40. 10.1111/ctr.12743

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 28.

  Del BelloACongy-JolivetNSallustoFGuilbeau-FrugierCCardeau-DesanglesIFortMet alDonor-specific antibodies after ceasing immunosuppressive therapy, with or without an allograft nephrectomy. Clin J Am Soc Nephrol (2012) 7(8):1310–9. 10.2215/CJN.00260112

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 29.

  NimmoAMSAMcIntyreSTurnerDMHendersonLKBattleRK. The impact of withdrawal of maintenance immunosuppression and graft nephrectomy on HLA sensitization and calculated chance of future transplant. Transpl Direct (2018) 4(12):e409. 10.1097/TXD.0000000000000848

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 30.

  LachmannNSchönemannCEl-AwarNEverlyMBuddeKTerasakiPIet alDynamics and epitope specificity of anti-human leukocyte antibodies following renal allograft nephrectomy. Nephrol Dial Transpl (2016) 31(8):1351–9. 10.1093/ndt/gfw041

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 31.

  SchachtnerTOttoNMSteinMReinkeP. Transplantectomy is associated with presensitization with donor-reactive T cells and graft failure after kidney retransplantation: a cohort study. Nephrol Dial Transpl (2018) 33(5):889–96. 10.1093/ndt/gfy002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 32.

  MartinKCantwellLBarracloughKALianMMastersonRHughesPDet alProlonged immunosuppression does not improve risk of sensitization or likelihood of retransplantation after kidney transplant graft failure. Transpl Int (2021) 34(11):2353–62. 10.1111/TRI.13998

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 33.

  LucisanoGBrookesPSantos-NunezEFirminNGunbyNHassanSet alAllosensitization after transplant failure: the role of graft nephrectomy and immunosuppression – a retrospective study. Transpl Int (2019) 32(9):949–59. 10.1111/tri.13442

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 34.

  AugustineJJWoodsideKJPadiyarASanchezEQHricikDESchulakJA. Independent of nephrectomy, weaning immunosuppression leads to late sensitization after kidney transplant failure. Transplantation (2012) 94(7):738–43. 10.1097/TP.0B013E3182612921

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 35.

  LenaersJChristiaansMVan HeurnEVan HooffHVan Den Berg-LoonenE. Frequent but late donor-directed antibody formation after kidney transplantectomy within one month after grafting. Transplantation (2006) 81(4):614–9. 10.1097/01.tp.0000196726.91957.97

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 36.

  KhakharAKShahinianVBHouseAAMuirheadNHollombyDJLeckieSHet alThe impact of allograft nephrectomy on percent panel reactive antibody and clinical outcome. Transpl Proc (2003) 35(2):862–3. 10.1016/S0041-1345(02)04031-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 37.

  PiatosaBRubikJGrendaR. Is positive flow cytometric cross-match a risk factor for early cadaveric kidney graft dysfunction?Transpl Proc (2006) 38(1):53–5. 10.1016/j.transproceed.2005.12.081

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 38.

  NainiAEHarandiAADaemiPKosariRGharaviM. Outcome of patients without any immunosuppressive therapy after renal allograft failure. Saudi J Kidney Dis Transpl (2008) 19(1):59–61. Available online at: https://pubmed.ncbi.nlm.nih.gov/18087124/(Accessed March 2, 2026).

  • Pubmed Abstract
  • Google Scholar

• 39.

  MartínezDMTorío RuízALorenzo GonzálezIMartínezRRLlamas FuentesFGonzalvo DíazCet alAnti-HLA antibodies after precocious transplantectomy by vascular thrombosis. Transpl Proc (2018) 50(2):546–9. 10.1016/j.transproceed.2018.01.002

  • CrossRef
  • Google Scholar

• 40.

  BillenEVAChristiaansMHLLeeJVan Den Berg-LoonenEM. Donor-directed HLA antibodies before and after transplantectomy detected by the luminex single antigen assay. Transplantation (2009) 87(4):563–9. 10.1097/TP.0B013E3181949E37

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 41.

  AdeyiOAGirnitaALHoweJMarrariMAwadallaYAskarMet alSerum analysis after transplant nephrectomy reveals restricted antibody specificity patterns against structurally defined HLA class I mismatches. Transpl Immunol (2005) 14(1):53–62. 10.1016/j.trim.2005.01.001

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 42.

  SchrezenmeierELehnerLJMerkelMMayrdorferMDuettmannWNaikMGet alWhat happens after graft loss? A large, long-term, single-center observation. Transpl Int (2021) 34(4):732–42. 10.1111/TRI.13834

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 43.

  MarrariMDuquesnoyRJ. Detection of donor-specific HLA antibodies before and after removal of a rejected kidney transplant. Transpl Immunol (2010) 22(3-4):105–9. 10.1016/J.TRIM.2009.12.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 44.

  García MontemayorVAgüeraMLRabascoCNavarroMDRodríguez BenotAAljamaP. Development of donor-specific Anti-HLA antibodies after restarting hemodialysis due to graft failure. Transpl Proc (2015) 47(9):2626–30. 10.1016/J.TRANSPROCEED.2015.10.018

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 45.

  KosmoliaptsisVGjorgjimajkoskaOSharplesLDChaudhryANChatzizachariasNPeacockSet alImpact of donor mismatches at individual HLA-A, -B, -C, -DR, and -DQ loci on the development of HLA-Specific antibodies in patients listed for repeat renal transplantation. Kidney Int (2014) 86(5):1039–48. 10.1038/ki.2014.106

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 46.

  QuenumAJISantharamMARamanathanSIlangumaranS. Inflammatory cytokines that enhance antigen responsiveness of naïve CD8+ T lymphocytes modulate chromatin accessibility of genes impacted by antigen stimulation. Int J Mol Sci (2022) 23(22):14122. 10.3390/ijms232214122

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 47.

  MarchingoJMKanASutherlandRMDuffyKRWellardCJBelzGTet alT cell signaling. Antigen affinity, costimulation, and cytokine inputs sum linearly to amplify T cell expansion. Science (2014) 346(6213):1123–7. 10.1126/science.1260044

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 48.

  RamanathanSGagnonJIlangumaranS. Antigen-nonspecific activation of CD8+ T lymphocytes by cytokines: relevance to immunity, autoimmunity, and cancer. Arch Immunol Ther Exp (Warsz) (2008) 56(5):311–23. 10.1007/s00005-008-0033-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 49.

  MilongoDKamarNDel BelloAGuilbeau-FrugierCSallustoFEspositoLet alAllelic and epitopic characterization of intra-kidney allograft Anti-HLA antibodies at allograft nephrectomy. Am J Transplant (2016) 17:420–31. 10.1111/ajt.13958

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 50.

  AchingerSGAyusJCKumarATsalatsanisA. Repeat transplantation rate of patients receiving dialysis after allograft nephrectomy. Kidney Med (2026) 8(1):101157. 10.1016/j.xkme.2025.101157

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 51.

  WangKXuXFanMQianfengZ. Allograft nephrectomy vs. no-allograft nephrectomy for renal transplantation: a meta-analysis. Clin Transpl (2016) 30(1):33–43. 10.1111/ctr.12654

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 52.

  FrontczakAPrudhommeTDel BelloAKassabDSoorojeballyYKleinclaussFet alAllograft nephrectomy: indications and surgical techniques. Association Française d’Urologie and Société Francophone de Transplantation guidelines. French J Urol (2025) 35(11):102940. 10.1016/j.fjurol.2025.102940

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 53.

  KainzAKammerMReindl-SchwaighoferRStrohmaierSPetrVViklickyOet alWaiting time for second kidney transplantation and mortality. Clin J Am Soc Nephrol (2022) 17:90–7. 10.2215/CJN.07620621

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 54.

  FragosoPBorgesACarameloFSáHOFigueiredoAAlvesRet alThe impact of immunosuppression withdrawal strategies on sensitization and safety outcomes after kidney transplant failure: a systematic review with meta-analysis. Transpl Rev (2026) 40(1):100982. 10.1016/j.trre.2025.100982

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 55.

  NabilACongy-JolivetNDarresAGuyPMarionOMilhesJet alImmediate and gradual withdrawal of immunosuppression after kidney graft loss lead to similar outcomes. Transpl Int (2026) 39:15642. 10.3389/TI.2026.15642

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 56.

  AllesinaALavaccaAFopFGiraudiRGiovinazzoGDeaglioSet alSignificant long-term prevention of high sensitization after kidney allograft failure by maintaining calcineurin inhibitor-based immunosuppression. Clin Transpl (2024) 38(7):e15394. 10.1111/ctr.15394

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 57.

  LealRFragosoPVendaJGomesJInácioMGuedes MarquesMet alProlonging calcineurin inhibitor therapy post kidney allograft failure: a prospective study. Ren Fail (2025) 47(1):2483386. 10.1080/0886022X.2025.2483386

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 58.

  CaseyMJWenXKaylerLKAiyerRScornikJCMeier-KriescheHU. Prolonged immunosuppression preserves nonsensitization status after kidney transplant failure. Transplantation (2014) 98(3):306–11. 10.1097/TP.0000000000000057

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 59.

  ScornikJCBrombergJSNormanDJBhanderiMGitlinMPetersenJ. An update on the impact of pre-transplant transfusions and allosensitization on time to renal transplant and on allograft survival. BMC Nephrol (2013) 14(1):217. 10.1186/1471-2369-14-217

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 60.

  MazzucchiENahasWCAntonopoulosIMPiovesanACIanhezLEArapS. Surgical complications of graft nephrectomy in the modern transplant era. J Urol (2003) 170(3):734–7. 10.1097/01.ju.0000080566.42381.94

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 61.

  LinJWangRXuYChenJ. Impact of renal allograft nephrectomy on graft and patient survival following retransplantation: a systematic review and meta-analysis. Nephrol Dial Transpl (2018) 33(4):700–8. 10.1093/ndt/gfx360

  • Pubmed Abstract
  • CrossRef
  • Google Scholar