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Summary The incidence and relevance of histological findings in removed allografts is unknown. In this study, we investigated the outcome of routine histopathological examination of removed allografts. We performed a retrospective cohort study in patients with kidney graft failure ≥3 months after transplantation. In this cohort, 244 allograft nephrectomies were performed. We routinely sent removed grafts for histopathological examination. In 197 cases, a pathology report was available for analysis. In 21 of the 197 grafts, gross necrosis precluded adequate interpretation. Signs of rejection were reported in 163 of the remaining 176 allografts. Recurrences of the original disease were found in 13 cases. These were all known from prior biopsies. Relevant secondary findings were present in eight cases: renal cell carcinoma (n = 2), urothelial cell carcinoma, candida pyelonephritis (n = 2), post‐transplant lymphoproliferative disease, polyomavirus inclusions, and membranous nephropathy. All conditions were diagnosed before graft nephrectomy, except for one case of papillary renal cell carcinoma of 0.8 cm. As expected, signs of acute and/or chronic rejection are the main histopathological finding in grafts that are removed after late graft failure. Unexpected secondary findings are very rare. Therefore, it is justifiable to restrict histopathological examination of removed kidney allografts to specific cases.

Background Graft nephrectomy is recommended in case of early graft failure. When the graft fails more than 3-6 months after transplantation it is current practice to follow a wait-and-see policy. A common indication for graft removal is the graft intolerance syndrome. We aimed to create a risk prediction model for the occurrence of graft intolerance resulting in graft nephrectomy. Methods We collected data of kidney transplantations performed in our centre between 1980 and 2010 that failed at least 6 months after transplantation. We evaluated the association between baseline characteristics and the occurrence of graft nephrectomy because of graft intolerance using a competing risk regression model. Prognostic factors were included in a multivariate prediction model. Results In and -exclusion criteria were met in 288 cases. In 48 patients the graft was removed because of graft intolerance. Donor age, the number of rejections and shorter graft survival were predictive factors forgraft nephrectomy because of the graft intolerance syndrome. These factors were included in a prediction rule. Conclusion Using donor age, graft survival, and the number of rejections, clinicians can predict the need for graft nephrectomy with a reasonable accuracy. This article is protected by copyright. All rights reserved.

Item does not contain fulltext Late allograft loss in kidney transplant recipients remains a common problem and is associated with high mortality and morbidity. The management of patients with a failed kidney allograft includes a few major dilemmas: when to start dialysis, what is the optimal management regarding immunosuppression, and should an allograft nephrectomy be performed. In suitable candidates for a repeated transplantation there are additional matters to take in consideration. In this review we will discuss these dilemmas by providing an overview of current evidence and gaps in our knowledge. As many of these issues are incompletely resolved, we conclude that more studies are needed to improve the management of patients with a failed kidney allograft.