A single-center study of the technical aspects and outcome of third and subsequent renal transplants.

BACKGROUND: Third, fourth, and fifth renal transplants are historically associated with poor outcomes. The reasons for these inferior results are unclear. In the current work, we analyzed the outcome of third and subsequent transplants and determined whether technical failure accounted for significant allograft loss.
METHODS: The outcome and operative details of 49 transplants performed in 38 patients from a single center were reviewed. Thirty-eight patients received a third transplant, nine patients received a fourth transplant, and two patients received a fifth transplant.
RESULTS: Actuarial patient survival was 100% and 97% at 5 and 10 years, respectively. One- and 5-year actuarial graft survival for third transplants was 90% and 62%, respectively, and for fourth transplants, 67% and 55%, respectively. Technical failure accounted for the loss of 2 third allografts and for no fourth or fifth allografts. Of the remaining third grafts, 12 failed as the result of chronic allograft nephropathy, and one failed as the result of recurrent membranoproliferative glomerulonephritis (type I). Of the fourth allografts, one failed as the result of acute rejection, two failed as the result of chronic allograft nephropathy, and one failed as the result of primary nonfunction. The mean graft survival of third and fourth transplants after a biopsy-proven acute rejection episode requiring steroid boost was significantly reduced. Of the fifth transplants, one graft failed as the result of hyperacute rejection, and one patient died with a functioning graft. Favorable human leukocyte antigen matching and a panel-reactive antibody less than 80% provided no statistical benefit to graft survival.
CONCLUSIONS: The major cause of graft loss of third and fourth renal transplants is immune mediated. Although technically demanding, surgical failure is an unusual cause of graft loss.