Objective To explore the treatment patterns of transplantation recipients with renal allograft dysfunction(RAD)by surgeons at transplantation centers nationwide and provide clinical references for managing such recipients.Methods From December 1,2022 to February 28,2023,surgeons from 148 transplant centers with kidney transplantation(KT)qualification in China were surveyed.A questionnaire on treating recipients with RAD was distributed via WeChat through the platform of Questionnaire Star.The questionnaire focused upon three aspects:immunosuppressive treatment patterns of transplant recipients with RAD,choice of subsequent renal replacement therapy and management of transplanted kidneys with loss of function.Results A total of 191 questionnaires were harvested from 90 transplant centers in China.Surgeons participating in this survey included 59 chief physicians,63 deputy chief physicians,55 attending physicians and 13 residents.For RAD recipients undergoing retransplantation within 1 year or after 1 year inclusive,58％(110/190)and 28％(54/190)of surgeons recommended that recipients stayed on their original immunosuppressive regimens.In both groups,37％(45/122)and 68％(83/122)of senior surgeons and 51％(35/68)and 78％(53/68)of non-senior surgeons recommended that RAD recipients tapered immunosuppression.In both groups,15％(29/190)and 25％(48/190)of surgeons advised recipients to lower original immunosuppressant dosage from original regimen;13％(25/190)and 17％(33/190)of surgeons recommended that regimen tailoring to recipient status;7％(14/190)and 13％(25/190)of surgeons recommended that recipients first discontinued mycophenolic acid(MPA)and followed up with low doses of the remaining medications.In both groups,75％(6/8)and 74％(17/23)of senior surgeons recommended discontinuing MPA no later than 3 months,and 70％(7/10)and 62％(8/13)of non senior surgeons recommended discontinuing MPA no later than 6 months.The most common indication for removing transplanted kidney was recurring signs and symptoms of rejection in recipient[80％(152/190)].The decision as to when a patient resuming dialysis was based primarily on clinical symptoms[80％(151/190)],creatinine[78％(148/190)]and surgeon's own clinical experience[56％(106/190)]in recipients with graft loss.94％(179/190)of surgeons recommended retransplantation in graft loss recipients.50％(95/190)of surgeons reported that the proportion of such recipients was less than 20％and only 8％(16/190)of the respondents reported that the proportion of such recipients was over 50％.Regarding the influencing factors of whether or not recommending retransplantation for RAD recipients,the participating surgeons considered the recipient's risk of sensitization[95％(180/190)],compliance[88％(167/190)],risk of infection[85％(162/190)],recipient's own willingness to undergo retransplantation[85％(162/190)]and recipient's family's willingness to undergo retransplantation[79％(162/190)].Transplantation[79％(150/190)]was the most important factor.For RAD recipients of retransplantation,36％(69/190)of surgeons recommended rechecking panel reactive antibodies(PRA)every 6 months while 28％(54/190)recommended registration.The remaining 28％(54/190)of surgeons recommended one review at the time of registration for retransplantation.Conclusion For RAD recipients,most surgeons recommend maintenance of original immunosuppressive regimen for recipients who expect to be viable for retransplantation at Year 1.Among surgeons recommending tapering immunosuppressive use,the most common approach was maintaining the original regimen at a reduced dose,tailoring the regimen to recipient status and keeping CNI at a reduced dose in conjunction with steroids after first discontinuing MPA.Senior surgeons were more cautious in tapering and had a shorter time window for discontinuing MPA analogs.For therapeutic TN procedures,participating surgeons preferred to perform TN when a recipient had recurring signs and symptoms of rejection.With regard to timing of dialysis resumption,the decision was based largely upon clinical symptoms,creatinine and personal experience.Most surgeons believe that re transplantation is an optimal renal replacement therapy for RAD recipients.However,the proportion of RAD recipients registering for retransplantation before resumption of dialysis is not high in China.Recipient education should be strengthened to boost the proportion of secondary transplantation.The risk of sensitization and recipient compliance are important influencing factors for surgeons recommending retransplantation.HLA antibody detection and recipient compliance should be emphasized.
Kidney transplantationGraft dysfunctionImmunosuppresantRenal replacement therapyAllograft nephrectomySurvey research
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