Revisiting maintenance immunosuppression in patients with renal transplant failure: early weaning of immunosuppression versus prolonged maintenance—systematic review and meta-analysis

Introduction Prolonged immunosuppression after dialysis start has been assumed to reduce sensitization, need for graft nephrectomy, and to favor re-transplantation. In contrast, immunosuppression is considered to increase the risk of mortality, infection, and malignancy. We aimed to assess the evidence regarding superiority of early or late withdrawal of maintenance immunosuppression post renal transplant failure. Methods A literature search of the PubMed, WOS, Ovid, and Scopus databases was conducted. Combined relative risks, (RRs), mean differences, and 95% confidence intervals (CIs) were calculated by using a random-effect model. Results Ten studies involving 1187 patients with kidney transplant failure were included. No difference could be detected between patients with early withdrawal of immunosuppressive drugs (≤ 3 months) or prolonged immunosuppressive treatment (> 3 months) regarding mortality (95% CI 0.91–2.28), panel reactive antibodies (PRAs) (95% CI − 0.75–30.10), re-transplantation rate (95% CI 0.55–1.35), infectious episodes (95% CI 0.67, 1.17), cancer (95% CI 0.26–1.54), and graft nephrectomy (95% CI 0.82–1.63). Similarly, no difference was found between immunosuppressive drug withdrawal over < 6 or ≥ 6 months regarding mortality (95% CI 0.16, 2.89), re-transplantation rate (95% CI 0.85–1.55), cancer (95% CI 0.37–1.63), and allograft nephrectomy (95% CI 0.87–4.33). Conclusion Prolonged maintenance immunosuppression post kidney transplant failure is not associated with increased risk of mortality, infection, or malignancy, or reduced risk of sensitization or allograft nephrectomy compared with early withdrawal.