The impact of immunosuppression withdrawal strategies on sensitization and safety outcomes after kidney transplant failure: A systematic review with meta-analysis.

BACKGROUND

Kidney transplant recipients with graft failure face reduced access to retransplantation due to sensitization. Evidence-based guidance on optimal immunosuppression (IS) management after graft loss is limited. This systematic review with meta-analysis assessed the impact of rapid versus prolonged IS withdrawal on sensitization and safety outcomes.

METHODS

Cohort studies comparing IS withdrawal strategies after graft failure were systematically reviewed. Outcomes included HLA sensitization, graft nephrectomy, hospitalization, and mortality. Searches were conducted in Medline, Embase, and the Cochrane Library. Pooled odds ratios (ORs) and weighted mean differences (WMD) were calculated using a random-effects model.

RESULTS

Thirteen studies comprising 1531 patients were included. Prolonging immunosuppression (>3 months of at least two immunosuppressants) was associated with significantly lower odds of graft exclusion (OR 0.41; 95 % CI 0.27-0.64), and a trend toward reduced donor-specific antibody formation and cPRA stabilization, although not statistically significant. Sensitivity analysis confirmed an association between early IS withdrawal and higher cPRA at follow-up (WMD +0.30, 0.01-0.59). The IS withdrawal strategy did not impact hospitalization, mortality, or retransplantation.

CONCLUSION

Prolonging IS after kidney graft failure reduces nephrectomy risk and favours a decrease in HLA sensitization, without added morbidity and mortality. Further prospective studies are warranted to provide stronger evidence-based data.