Introduzione: Nell'ultimo decennio l'aumento di attività di trapianto renale, migliore alternativa di sopravvivenza per il trattamento dell'uremia terminale, ha avuto come conseguenza una maggiore numerosità di rientri in dialisi per fallimento di trapianto (FTpx). Si è venuta ad identificare una popolazione fragile per la quale pochi sono gli studi di coorte nè esistono linee guida di approccio clinico. Risultati: I pazienti con FTpx avevano all'ingresso in dialisi una funzionalità renale residua superiore rispetto al gruppo di controllo (GFR 13.6 ml/min vs 10.6 ml/min p=0.04). L'emodialisi costituiva la terapia di scelta (45/46 casi), l'accesso vascolare era rappresentato dalla fistola artero-venosa nel 60.8% dei casi. Le dosi di eritropoietina (U/sett) erano di 8702 ± 5594 vs 4800±4489 nei controlli (p=0.019), l'albuminemia (34. Methods: this is a ten-year retrospective cohort study on 46 patients who failed kidney transplant (FKTpx) compared to transplant naïve controls followed-up in the Nephrology Department, and literature cohorts.Results: FKTpx started dialysis with better residual renal function as compared to transplant naïve subjects (GFR 13.6 ml/min vs 10.6 ml/min p=0.04), hemodialysis was the therapy of choice (45/46 cases (98%)), arterio-venous fistula was the first vascular access in 28/45 (60.8%) of the patients.Erythropoietin dosage (U/week) was 8,702 ± 5,594 vs 4,800 ± 4,489, respectively (p=0.019), mean serum albumin was lower (34.3 ± 5.3) in FKTpx than in controls, while it normalized at the end of follow-up. Twenty-one transplantectomies (TPxN) were carried out, 11 of which (7.2 ± 5.6 months after starting dialysis) were due to acute rejection and/or chronic inflammatory state. Erythropoietin dosage and C reactive protein significantly increased (p=0.03 and p=0.04, respectively) between dialysis start and TPxN and significantly decreased at the end of follow-up (p=0.012, p=0.047, respectively).De novo DSA and total anti HLA antibodies increased after TPxN (p=0.001), but also after discontinuation of immunosuppression without TPxN (p=0.03) and persisted until the end of follow-up (p=0.03). Nine deaths were censored (mortality rate 19.5%). Among the remaining 37 patients, cardiovascular ischemic events occurred during follow-up in 16 subjects (43.2%). One patient died of acute myocardial infarction. Overall infection rate was 58.5%; 16.6% were hemodialysis central-venous-catheter-related, while 2 died of sepsis.Five patients developed solid tumors (functioning graft 91.2 ± 74.9; 20.6 ± 15.5 months after resuming dialysis). To date, 20 patients are on regular dialysis, and 17 patients have successfully undergone kidney re-transplantation.Conclusions: This cohort study highlights that FTpx represent a unique subgroup of fragile patients with higher rates of first-year mortality as compared to the global dialytic pool. In order to ameliorate long term survival we suggest starting dialysis and setting up definitive vascular access for hemodialysis as soon as possible, and improving nutritional status. Beyond infection-related problems, this population requires careful clinical evaluation. We propose a scheduled program which would be useful for monitoring immunosuppression weaning and withdrawal. This clinical situation may lead to a disabling, sometimes hidden, chronic inflammatory state resulting in transplantectomy.The role of anti HLA antibodies and de novo DSA formation is still debated.