Management of patients with a failed kidney transplant: Dialysis reinitiation, immunosuppression weaning, and transplantectomy

Table 4 Suggested immunosuppression withdrawal protocols based on maintenance therapy

CNI + antimetabolitea + prednisone	CNI + mTOR inh + prednisone	mTOR inh + prednisone
Discontinue antimetabolite at initiation of dialysis	Discontinue mTOR inh at initiation of dialysis	Taper mTOR inh over 4-6 wkb
Taper CNI over	Taper CNI over	Maintain same steroid dose at initiation of dialysis x 2-4 wk, then taper by 1 mg/mo (starting from 5 mg daily) until off
4-6 wkb	4-6 wkb
Maintain same steroid dose at initiation of dialysis x 2-4 wk, then taper by 1 mg/mo (starting from 5 mg daily) until off	Maintain same steroid dose at initiation of dialysis x 2-4 wk, then taper by 1 mg/mo (starting from 5 mg daily) until off

^aMycophenolate Mofetil (Cellcept^®) or Mycophenolic Acid (Myfortic^®) or Azathioprine (Imuran^®);

^bTaper can be done over a shorter period in slow chronic progressive graft failure but over a longer period when graft failure occurred following recent acute rejection episodes. CNI: Calcineurin inhibitor; mTOR inh: Mammalian target of rapamycin inhibitor.