[Immunosuppressive treatment in patients starting peritoneal dialysis after functional arrest of kidney transplant. What to do?].

The growing number of kidney patients who have to restart dialysis after functional failure of a kidney transplant has brought to this context the general controversy on dialysis modality selection criteria. These should be applied from a longterm perspective, since each patient may benefit more from one treatment or another at different times in his clinical course. When the issue is analyzed from a general perspective, peritoneal dialysis and hemodialysis seem to provide similar results in renal transplant patients, although the available information is still insufficient. The crucial prognostic nature of residual renal function in incident patients on peritoneal dialysis brings up the issue of wether it is appropriate to maintain some type of immunosuppression after restarting dialysis, at least until total failure of graft function. This decision is currently based on purely empirical considerations, since we do not have reliable information to answer the key questions. Thus, we do not know if residual renal function has the same importance in this context as in the overall renal population. Neither if withdrawal of maintenance of immunosuppression will presumably have the same effect in all cases. The side effects of maintaining partial immunosuppression and the overall clinical yield for the patient are also not well defined. Finally, it is unclear what immunosuppression should be maintained, although there is agreement that it should be lowgrade; steroids and to lesser extent calcineurin inhibitors are the preferred agents, but always on empirical grounds. Because of the growing importance of this subpopulation of renal patients, these questions should be answered in a systematic manager in coming years.