Can a transplant ever fail and what happens then? 

Yes, a kidney transplant can fail, either shortly after the operation or many years later. While most transplants are successful, organ failure can occur due to acute rejection, surgical complications, or a slow process of scarring known as chronic rejection. If a transplant fails, it is not considered a medical failure of the patient; rather, it is a transition back to other forms of renal replacement therapy. In the UK, patients whose transplants are failing are supported by their renal team to transition safely back to dialysis or, in many cases, to prepare for a second transplant. 

The prospect of a transplant failing can be emotionally and physically challenging. However, it is important to remember that a transplant is a treatment, not a permanent cure. Many people in the UK have lived successfully with multiple transplants over several decades. Understanding why failure happens and what the next steps are can help you and your family prepare for this possibility and ensure you continue to receive life-saving care. 

What We Will cover in This Article 

• Differentiation between early and late transplant failure 

• Common causes of gradual organ decline over time 

• Clinical triggers that indicate a transplant is starting to fail 

• The emotional impact of returning to dialysis after a transplant 

• The process of being listed for a second or subsequent transplant 

• Managing medications during the transition back to dialysis 

• Practical steps for choosing the right dialysis modality for a second time 

Differentiation between early and late failure 

Clinical teams differentiate between ‘early’ and ‘late’ graft failure because the causes and management strategies are very different. Early failure occurs within the first few days or weeks after surgery. This is often caused by a surgical emergency, such as a blood clot in the renal artery (thrombosis) or a hyperacute immune response. In these rare cases, the kidney may need to be removed immediately. 

Late failure happens years after the transplant. This is the most common form of failure and is usually a slow, progressive decline. The primary cause is ‘chronic allograft nephropathy’ a gradual buildup of scar tissue within the kidney. This is often triggered by a combination of the immune system’s long-term activity, high blood pressure, and the side effects of the anti-rejection medications themselves. 

Causes of gradual transplant decline 

The decline of a transplanted kidney is rarely sudden. It is usually a slow process that unfolds over several months or years. One major cause is the return of the original disease that caused the patient’s own kidneys to fail, such as certain types of glomerulonephritis. Another cause is ‘non-adherence’ if a patient has struggled to take their immunosuppressants consistently over many years, it can trigger silent, low-level rejection that scars the kidney. 

Vascular issues are also a significant cause. Just like your natural kidneys, a transplanted kidney relies on healthy blood vessels. If a patient develops significant heart disease or severe high blood pressure, the delicate filters in the donor kidney can become damaged. This differentiation is why your ‘Annual MOT’ focuses so heavily on your heart and blood pressure, not just your creatinine levels. 

Triggers for the transition back to dialysis 

The transition back to dialysis is triggered by your blood results and your physical symptoms. As the kidney fails, your creatinine and urea levels will begin to rise consistently. You may start to experience symptoms similar to those you had before your transplant, such as: 

• Persistent fatigue and lethargy 

• Swelling in the ankles or legs (fluid retention) 

• A metallic taste in the mouth or loss of appetite 

• Itchy skin or a general feeling of being unwell 

When your kidney function (GFR) falls below a certain level usually around 15% your renal team will start a ‘low clearance’ or ‘pre-dialysis’ clinic routine. This is a clinical trigger to discuss which type of dialysis will suit your current lifestyle. Some patients who used haemodialysis before may choose peritoneal dialysis the second time, or vice versa, depending on how their life has changed since their transplant. 

The process of seeking a second transplant 

For many people, the failure of one transplant is the trigger to start preparing for the next one. You can be re-listed for the national transplant waiting list once your kidney function falls to a specific level (usually a GFR of 15% or less). In some cases, if you have a willing living donor, it may even be possible to have a ‘pre-emptive’ second transplant, meaning you receive the new organ before you even need to start dialysis. 

Factor	First Transplant	Second (or subsequent) Transplant
Surgical Difficulty	Standard	More complex due to existing scar tissue
Tissue Matching	Standard	More difficult (increased antibodies)
Waiting Time	Varies by blood group	May be longer if ‘highly sensitised’
Success Rate	Very High	High, but requires specialist management
Organ Placement	Usually the right side	Often the left side or higher up

A second transplant can be more complex because your immune system may have developed antibodies from the first kidney. This is called being ‘sensitised’. In the UK, the national allocation system gives extra points to highly sensitised patients to help them find a compatible match, ensuring they are not disadvantaged by their previous transplant. 

Managing medications after failure 

A critical part of managing a failing transplant is the careful ‘tapering’ of your immunosuppressant medications. If you are returning to dialysis, your doctors will gradually reduce your anti-rejection drugs. This differentiation is important: you need enough medicine to prevent a sudden, painful inflammation of the failing kidney (graft intolerance), but not so much that you are at unnecessary risk of infection while on dialysis. 

In some cases, if the failing kidney is causing pain, fever, or blood in the urine, it may need to be surgically removed (a graft nephrectomy). However, in many cases, the old transplant is left exactly where it is, and the second transplant is simply placed on the opposite side of the abdomen. 

My final conclusion 

While the failure of a kidney transplant is a significant life event, it is a transition that the UK renal system is well-equipped to manage. Whether the cause is early surgical issues or long-term scarring, you will be supported in returning to dialysis or preparing for a second transplant. Most people who experience transplant failure go on to live many more years through other treatments, and the ‘gift of life’ often comes more than once. 

If you experience severe, sudden, or worsening symptoms, such as sudden chest pain, severe breathlessness, or a total inability to pass urine, call 999 immediately. 

Authority Snapshot 

This article was written by Dr. Rebecca Fernandez, a UK-trained physician with an MBBS and experience in general surgery, cardiology, internal medicine, and emergency care. Dr. Fernandez has significant experience in managing the transition of care for complex renal patients and stabilising those with declining organ function. Her background ensures this guide on transplant failure is medically accurate, safe, and aligned with current UK clinical practice.