Dialysis After Graft Loss in Portugal: A National Survey of Nephrologists’ Practices and Perspectives
DOI:
https://doi.org/10.71749/pkj.147Keywords:
Graft Rejection, Kidney Failure, Chronic, Kidney Transplantation, Nephrology, Practice Patterns, Physicians, Renal Dialysis, Renal Replacement Therapy, Surveys and QuestionnairesAbstract
Introduction: Kidney graft loss is a leading cause of dialysis initiation — dialysis after graft loss (DAGL) — and is associated with substantial morbidity and mortality. The absence of robust guidelines has resulted in considerable variability in clinical practice. This study aimed to characterize Portuguese nephrologists’ perspectives on the best management of DAGL patients.
Methods: We conducted an observational, cross-sectional, web-based descriptive-exploratory study among Portuguese nephrologists using an anonymous online questionnaire. The survey was designed to capture professional opinions rather than to audit actual clinical activity. Closed-ended responses were analyzed descriptively. Free-text comments were examined using inductive thematic analysis.
Results: Fifty-six nephrologists responded. With respect to dialysis initiation, 78.6% indicated that uremic symptoms should take priority over strict eGFR thresholds, and 83.9% considered the choice of dialysis modality to be a case-by-case decision. At stage 5T, 55.5% endorsed an individualized approach to immunosuppression. After graft failure, 53.6% considered progressive immunosuppression weaning when retransplantation was feasible, and 94.7% when it was not. In addition, 33.9% believed DAGL patients have worse survival outcomes than non-DAGL patients. For 80.4% of respondents, the perceived retransplantation rate was below 25%. Finally, 91.1% considered a harmonized national guideline useful.
Conclusion: The findings reveal substantial heterogeneity in professional opinion. Key areas of agreement include multidimensional stage 5T assessment, symptom-guided dialysis initiation, and immunosuppression weaning sequence. The greatest discordance emerged in vascular access planning, comorbidity management, and perceptions of DAGL outcomes. These results support the development of a harmonised, yet flexible, protocol for the management of DAGL patients.
Downloads
References
GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020;395:709–33. doi:10.1016/S0140-6736(20)30045-3
Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341:1725-30. doi: 10.1056/NEJM199912023412303.
Laupacis A, Keown P, Pus N, Krueger H, Ferguson B, Wong C, Muirhead N. A study of the quality of life and cost-utility of renal transplantation. Kidney Int. 1996;50:235-42. doi: 10.1038/ki.1996.307.
Coemans M, Süsal C, Döhler B, Anglicheau D, Giral M, Bestard O, et al. Analyses of the short- and long-term graft survival after kidney transplantation in Europe between 1986 and 2015. Kidney Int. 2018;94:964-73. doi: 10.1016/j.kint.2018.05.018.
Lamb KE, Lodhi S, Meier-Kriesche HU. Long-term renal allograft survival in the United States: a critical reappraisal. Am J Transplant. 2011;11:450-62. doi: 10.1111/j.1600-6143.2010.03283.x.
Tanriover C, Copur S, Basile C, Ucku D, Kanbay M. Dialysis after kidney transplant failure: how to deal with this daunting task? J Nephrol. 2023;36:1777-87. doi: 10.1007/s40620-023-01758-x.
Collins AJ, Foley RN, Gilbertson DT, Chen SC. United States Renal Data System public health surveillance of chronic kidney disease and end-stage renal disease. Kidney Int Suppl. 2015;5:2-7. doi: 10.1038/kisup.2015.2.
Gabinete de Registo da Sociedade Portuguesa de Nefrologia. Relatório Anual 2025. Lisboa: Sociedade Portuguesa de Nefrologia; 2026.
Schrezenmeier E, Lehner LJ, Merkel M, Mayrdorfer M, Duettmann W, Naik MG, et al. What happens after graft loss? A large, long-term, single-center observation. Transpl Int. 2021;34:732-42. doi: 10.1111/tri.13834.
Johansen KL, Chertow GM, Gilbertson DT, Ishani A, Israni A, Ku E, et al. US Renal Data System 2022 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2023;81:A8-A11. doi: 10.1053/j.ajkd.2022.12.001.
Kabani R, Quinn RR, Palmer S, Lewin AM, Yilmaz S, Tibbles LA, et al. Risk of death following kidney allograft failure: a systematic review and meta-analysis of cohort studies. Nephrol Dial Transplant. 2014;29:1778-86. doi: 10.1093/ndt/gfu205.
Gill JS, Abichandani R, Kausz AT, Pereira BJ. Mortality after kidney transplant failure: the impact of non-immunologic factors. Kidney Int. 2002;62:1875-83. doi: 10.1046/j.1523-1755.2002.00640.x.
Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review. J Clin Med. 2022;11:6108. doi: 10.3390/jcm11206108.
Pham PT, Everly M, Faravardeh A, Pham PC. Management of patients with a failed kidney transplant: Dialysis reinitiation, immunosuppression weaning, and transplantectomy. World J Nephrol. 2015;4:148-59. doi: 10.5527/wjn.v4.i2.148.
Bunthof KL, Hazzan M, Hilbrands LB. Review: Management of patients with kidney allograft failure. Transplant Rev. 2018;32:178-86. doi: 10.1016/j.trre.2018.03.001.
Drüeke TB, Parfrey PS. Summary of the KDIGO guideline on anemia and comment: reading between the (guide)line(s). Kidney Int. 2012;82:952-60. doi: 10.1038/ki.2012.270.
Haller MC, Kainz A, Baer H, Oberbauer R. Dialysis Vintage and Outcomes after Kidney Transplantation: A Retrospective Cohort Study. Clin J Am Soc Nephrol. 2017;12:122-30. doi: 10.2215/CJN.04120416.
Chan CT, Blankestijn PJ, Dember LM, Gallieni M, Harris DC, Lok CE, et al. Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2019;96:37-47. doi: 10.1016/j.kint.2019.01.017.
Perl J, Dong J, Rose C, Jassal SV, Gill JS. Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure? Perit Dial Int. 2013;33:618-28. doi: 10.3747/pdi.2012.00280.
Ryu H, Kim YC, Moon JJ, Song EY, Min SI, Ha J, et al. Weaning Immunosuppressant in Patients with Failing Kidney Grafts and The Outcomes: A Single-Center Retrospective Cohort Study. Sci Rep. 2020;10:6425. doi: 10.1038/s41598-020-63266-3.
Ayus JC, Achinger SG, Lee S, Sayegh MH, Go AS. Transplant nephrectomy improves survival following a failed renal allograft. J Am Soc Nephrol. 2010;21:374-80. doi: 10.1681/ASN.2009050480.
Johnston O, Rose C, Landsberg D, Gourlay WA, Gill JS. Nephrectomy after transplant failure: current practice and outcomes. Am J Transplant. 2007;7:1961-7. doi: 10.1111/j.1600-6143.2007.01884.x.
Leal R, Venda J, Sá HO, Figueiredo A, Alves R. Perspectives in Immunosuppression Management Following Renal Graft Failure: A Portuguese National Survey. Kidney Int Rep. 2024;9:2303-4. doi: 10.1016/j.ekir.2024.05.015.
Silva AR, Guedes Marques M, Rodrigues L, Santos L, Romãozinho C, Caramelo F, et al. Chronic kidney disease management in patients with a failing graft: a comparative study with incident non-transplant hemodialysis patients. Ren Fail. 2025;47:2447791. doi: 10.1080/0886022X.2024.2447791.
Gittus M, Bailey PK, Griffin S. Management of patients with a failing kidney transplant: a survey of UK-based renal units. Nephrol Dial Transplant. 2023;38:2086-8. doi: 10.1093/ndt/gfad084.
Caldés Ruisánchez S, Marcén Letosa R, Amezquita Orjuela Y, Fernández Lucas M, Rivera Gorrin M, Galeano Álvarez C, et al. Dialysis after kidney transplant failure: do patients start in a worse condition than the general population with chronic kidney disease? Nefrologia. 2011;31:51-7. doi: 10.3265/Nefrologia.pre2010.Nov.10610.
Naylor KL, Knoll GA, McArthur E, Garg AX, Lam NN, Field B, et al. Outcomes of an Inpatient Dialysis Start in Patients With Kidney Graft Failure: A Population-Based Multicentre Cohort Study. Can J Kidney Health Dis. 2021;8:2054358120985376. doi: 10.1177/2054358120985376.
Lubetzky M, Tantisattamo E, Molnar MZ, Lentine KL, Basu A, Parsons RF, et al. The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients. Am J Transplant. 2021;21:2937-49. doi: 10.1111/ajt.16717.
Fiorentino M, Gallo P, Giliberti M, Colucci V, Schena A, Stallone G, et al. Management of patients with a failed kidney transplant: what should we do? Clin Kidney J. 2020;14:98-106. doi: 10.1093/ckj/sfaa094.
Vajdič Trampuž B, Arnol M, Gubenšek J, Ponikvar R, Buturović Ponikvar J. A national cohort study on hemodialysis arteriovenous fistulas after kidney transplantation - long-term patency, use and complications. BMC Nephrol. 2021;22:344. doi: 10.1186/s12882-021-02550-4.
Zawistowski M, Nowaczyk J, Domagała P. Peritoneal dialysis catheter removal at the time or after kidney transplantation: a systematic review and meta-analysis. Langenbecks Arch Surg. 2022;407:2651-62. doi: 10.1007/s00423-022-02637-y.
Basile C, Casino FG, Mitra S; EuDial Working Group of the European Renal Association. Towards a tailored prescription of dialysis adequacy: the key role of incremental haemodialysis. Nephrol Dial Transplant. 2023;38:855-7. doi: 10.1093/ndt/gfac281.
Casino FG, Lopez T, Santarsia G, Mostacci SD, Sabato A, Di Carlo M, et al. Could incremental haemodialysis be a new standard of care? A suggestion from a long-term observational study. G Ital Nefrol. 2022;39:2022-vol3.
Woodside KJ, Schirm ZW, Noon KA, Huml AM, Padiyar A, Sanchez EQ, et al. Fever, infection, and rejection after kidney transplant failure. Transplantation. 2014;97:648-53. doi: 10.1097/01.TP.0000437558.75574.9c.
Aubert O, Loupy A, Hidalgo L, Duong van Huyen JP, Higgins S, Viglietti D, et al. Antibody-Mediated Rejection Due to Pre-existing versus De Novo Donor-Specific Antibodies in Kidney Allograft Recipients. J Am Soc Nephrol. 2017;28:1912-23. doi: 10.1681/ASN.2016070797.
Loupy A, Lefaucheur C. Antibody-Mediated Rejection of Solid-Organ Allografts. N Engl J Med. 2018;379(:1150-60. doi: 10.1056/NEJMra1802677.
Mourad G, Minguet J, Pernin V, Garrigue V, Peraldi MN, Kessler M, et al. Similar patient survival following kidney allograft failure compared with non-transplanted patients. Kidney Int. 2014;86:191-8. doi: 10.1038/ki.2014.6.
Mourad G, Szwarc I, Buzançais A. Retour en dialyse après échec de transplantation: comment améliorer les résultats dans cette population fragile? Néphrol Thérap. 2016;12:S89-S94. doi:10.1016/j.nephro.2016.01.007.
Knoll G, Muirhead N, Trpeski L, Zhu N, Badovinac K. Patient survival following renal transplant failure in Canada. Am J Transplant. 2005;5:1719-24. doi: 10.1111/j.1600-6143.2005.00921.x.
Leal R, Almiro E, Castro P, Duarte R, Rita Silva A, Guedes Marques M, et al. Clinical Frailty Scale and Charlson Comorbidity Index as predictors of hospitalization and mortality risk after kidney transplant failure. Nefrologia. 2025;45:501353. doi: 10.1016/j.nefroe.2025.501353.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Ricardo A. Macau, Inês Carmo Ferreira, José Oliveira da Costa, Rita Leal, Sara Gonçalves, Bernardo Silva, Filipe Marques, Fernando Abreu, Alice Santana, José António Lopes
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
