Priority 3 from the Kidney Transplant PSP

UNCERTAINTY: How can we prevent sensitisation in patients with a failing transplant, to improve their chances of another successful transplant (e.g. removal of the transplant, withdrawal of immunosuppressive medicines or continuation of these medicines?)
Overall ranking Priority questions agreed on but not put in ranked order
JLA question ID 0037/3
Explanatory note Not available for this PSP

Existing Systematic Review - Kabani, R., Quinn, R. R., Palmer, S., Lewin, A. M., Yilmaz, S., Tibbles, L. A., Lorenzetti, D L., Strippoli, G. F. M., McLaughlin, K., Ravani, P. Risk of death following kidney allograft failure: a systematic review and meta-analysis of cohort studies. Nephrology Dialysis Transplantation. 2014;29(9):1778-86 ~
Existing Randomised Controlled Trials: Ayus JC, Achinger SG, Lee S, Sayegh MH, Go AS. Transplant Nephrectomy Improves Survival following a Failed Renal Allograft. Journal of the American Society of Nephrology: JASN. 2010;21(2):374-380. doi:10.1681/ASN.2009050480
Ongoing Randomised Controlled Trial: Systematic Transplantectomy Versus Conventional Care After Kidney Graft Failure (DESYRE) - NCT01817504 

Health Research Classification System category Renal and Urogenital
Extra information provided by this PSP
Original uncertainty examples

When should we remove a failing graft? Should we withdraw immunosuppression on patients with failed transplants back on dialysis or should we do graft nephrectomies to reduce ongoing sensitisation for future transplants How can we limit anti-HLA antibody formation after kidney transplant failure? Which patients should have a graft nephrectomy? How should we manage the failed transplant?  Nephrectomy, immunosuppressive withdrawal or continuation for how long? What is the best immunosuppression for failing grafts (or already failed), CNI vs. Others

Comparison Surgery
Submitted by Clinicians x 6
Outcomes to be measured Sensitisation (CFR/PRA), surgical complications, retransplant rates, complications of immunosuppression (infection, malignancy)
PSP information
PSP unique ID 0037
PSP name Kidney Transplant
Total number of uncertainties identified by this PSP. 90  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 3 February 2016