The impact of immunosuppression withdrawal strategies on sensitization and safety outcomes after kidney transplant failure: A systematic review with meta-analysis.
Fragoso, P., et al.Transplant Rev (Orlando). 2026 Jan;40(1):100982.
Aims
The aim of this study was to compare the effect of two immunosuppression withdrawal strategies, rapid versus prolonged, on sensitization and safety outcomes following graft failure in kidney transplant recipients.
Interventions
EMBASE, MEDLINE (via PubMed) and the Cochrane Register of Controlled Trials was used to search for relevant literature. Study selection and data extraction were perfomed by two indepedent reviewers. Risk of bias of observational studies was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool.
Participants
13 studies were included in the review.
Outcomes
HLA sensitization, retransplantation, graft nephrectomy or embolization, patient mortality and hospitalisation.
Follow-up
N/A
CET Conclusions
There remains a great deal of uncertainty as to how to manage immunosuppression (IS) in patients with a failed graft. On the one-hand, IS minimisation or withdrawal reduces the infection and malignancy risks associated with long-term continuation, whilst on the other hand this may increase the risk of rejection and/or sensitisation reducing chances of retransplantation. This systematic review and meta-analysis explores the literature regarding IS management in patients with a failed kidney graft. The authors identified 13 studies (1531 patients) meeting inclusion criteria. Meta-analysis suggests that prolonging IS (2 agents for more than 3 months post-failure) reduces nephrectomy risk and demonstrates trends towards stabilisation of cPRA. Prolongation of IS did not appear to affect DSA formation, mortality or retransplantation rates. No data directly comparing infection or malignancy rates were found, but hospitalisation rates did not differ. Review methodology is very good, but the conclusions are limited by the observational nature of the included studies and overall moderate to high risk of bias, as well as high levels of heterogeneity in many analyses. In particular, there is a high risk of uncorrected confounding in the included studies. However, this review provides a very nice summary of the existing literature that could be used to aid the design of future prospective trials.
Trial registration
PROSPERO - CRD42024496706