Management of immunosuppression in the patient with a failed kidney transplant*

* Kidney transplant failure is defined as the loss of a kidney transplant requiring the reinitiation of dialysis.
¶ In patients who have been taking prednisone for longer than 3 months, we typically taper the prednisone to avoid the development of secondary adrenal insufficiency.
Δ In patients taking tacrolimus, we target 24-hour trough levels of 2 to 5 ng/mL. In patients taking cyclosporine, we target 24-hour trough levels of 50 to 75 ng/mL.
◊ In patients who have a planned retransplant within 1 year, we continue the calcineurin inhibitor since withdrawal of the calcineurin inhibitor has been shown to increase the risk of sensitization.
§ In patients who are frail and unlikely to tolerate an urgent transplant nephrectomy if needed within the next few months, we defer tapering the calcineurin inhibitor until the patient's overall physical condition improves. This avoids the risk of precipitating immediate rejection.
¥ If the patient is starting with a maintenance dose of prednisone that is >5 mg/day, we immediately reduce the dose to 5 mg/day and then begin the taper. Patients who are being tapered off of prednisone should be monitored for symptoms of adrenal insufficiency. Refer to UpToDate topics on the clinical features and diagnosis of adrenal insufficiency in adults.
‡ In patients with late graft failure who are not anuric and who do not have a planned retransplant within 1 year, this approach allows the patient to obtain the benefits of the additional solute and water clearance while on dialysis.