UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Overview of care of the adult kidney transplant recipient

Author
Anil Chandraker, MD, FASN, FRCP
Section Editor
Daniel C Brennan, MD, FACP
Deputy Editor
Albert Q Lam, MD

INTRODUCTION

Kidney transplantation is the treatment of choice for end-stage renal disease [1]. A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients when compared with maintenance dialysis [2-4]. However, patients require close follow-up after transplantation since they are on complex immunosuppressive regimens that render them susceptible to infection, malignancy, and cardiovascular disease (CVD). In addition, patients often have multiple comorbidities due to, or as a cause of, their underlying end-stage renal disease.

Whereas patients are generally followed by a transplant specialist for the first three to six months following transplant, thereafter they may be seen primarily by a general nephrologist or internist, who is often able to address existing comorbidities. Whether a patient is followed by a transplant nephrologist, general nephrologist, or internist often depends upon the availability of services in proximity to the patient. While many believe that transplant nephrologists should be directly involved in care of transplant recipients for the life of the graft, this is often not practical. Communication between the internist or community-based nephrologist and the transplant center is important for optimal care of the patient, however.

This topic reviews the general medical care of the kidney transplant recipient including recommendations for monitoring allograft function and minimizing the risk of infections, malignancies, bone disease, CVD, and diabetes. Common medical problems encountered after transplantation are also discussed.

Maintenance immunosuppressive therapy, allograft dysfunction, and patient survival following transplantation are discussed separately. (See "Maintenance immunosuppressive therapy in renal transplantation in adults" and "Chronic renal allograft nephropathy" and "Patient survival after renal transplantation".)

Specific complications of transplantation are discussed separately. (See "Urinary tract infection in renal transplant recipients" and "Hepatitis B virus infection in renal transplant recipients" and "Lipid abnormalities after renal transplantation" and "Prevention and management of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation" and "Hepatitis C infection in kidney transplant candidates and recipients" and "Hepatitis C virus infection in kidney donors" and "Hypertension after renal transplantation".)

                             

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Nov 25 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Suthanthiran M, Strom TB. Renal transplantation. N Engl J Med 1994; 331:365.
  2. Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in end-stage renal failure: evidence for reduced mortality risk compared with hemodialysis during long-term follow-up. J Am Soc Nephrol 1998; 9:2135.
  3. Port FK, Wolfe RA, Mauger EA, et al. Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 1993; 270:1339.
  4. Ojo AO, Port FK, Wolfe RA, et al. Comparative mortality risks of chronic dialysis and cadaveric transplantation in black end-stage renal disease patients. Am J Kidney Dis 1994; 24:59.
  5. Gotti E, Perico N, Perna A, et al. Renal transplantation: can we reduce calcineurin inhibitor/stop steroids? Evidence based on protocol biopsy findings. J Am Soc Nephrol 2003; 14:755.
  6. Levy G, Thervet E, Lake J, et al. Patient management by Neoral C(2) monitoring: an international consensus statement. Transplantation 2002; 73:S12.
  7. Thervet E, Pfeffer P, Scolari MP, et al. Clinical outcomes during the first three months posttransplant in renal allograft recipients managed by C2 monitoring of cyclosporine microemulsion. Transplantation 2003; 76:903.
  8. Cole E, Maham N, Cardella C, et al. Clinical benefits of neoral C2 monitoring in the long-term management of renal transplant recipients. Transplantation 2003; 75:2086.
  9. Gaston RS. Maintenance immunosuppression in the renal transplant recipient: an overview. Am J Kidney Dis 2001; 38:S25.
  10. Anglicheau D, Verstuyft C, Laurent-Puig P, et al. Association of the multidrug resistance-1 gene single-nucleotide polymorphisms with the tacrolimus dose requirements in renal transplant recipients. J Am Soc Nephrol 2003; 14:1889.
  11. Thervet E, Anglicheau D, King B, et al. Impact of cytochrome p450 3A5 genetic polymorphism on tacrolimus doses and concentration-to-dose ratio in renal transplant recipients. Transplantation 2003; 76:1233.
  12. Tsuchiya N, Satoh S, Tada H, et al. Influence of CYP3A5 and MDR1 (ABCB1) polymorphisms on the pharmacokinetics of tacrolimus in renal transplant recipients. Transplantation 2004; 78:1182.
  13. Nankivell BJ, Borrows RJ, Fung CL, et al. The natural history of chronic allograft nephropathy. N Engl J Med 2003; 349:2326.
  14. Land W, Vincenti F. Toxicity-sparing protocols using mycophenolate mofetil in renal transplantation. Transplantation 2005; 80:S221.
  15. Hohage H, Kleyer U, Brückner D, et al. Influence of proteinuria on long-term transplant survival in kidney transplant recipients. Nephron 1997; 75:160.
  16. Roodnat JI, Mulder PG, Rischen-Vos J, et al. Proteinuria after renal transplantation affects not only graft survival but also patient survival. Transplantation 2001; 72:438.
  17. Fernández-Fresnedo G, Escallada R, Rodrigo E, et al. The risk of cardiovascular disease associated with proteinuria in renal transplant patients. Transplantation 2002; 73:1345.
  18. Furness PN, Philpott CM, Chorbadjian MT, et al. Protocol biopsy of the stable renal transplant: a multicenter study of methods and complication rates. Transplantation 2003; 76:969.
  19. Schwarz A, Gwinner W, Hiss M, et al. Safety and adequacy of renal transplant protocol biopsies. Am J Transplant 2005; 5:1992.
  20. Osorio JM, Bravo J, Pérez A, et al. Magnesemia in renal transplant recipients: relation with immunosuppression and posttransplant diabetes. Transplant Proc 2010; 42:2910.
  21. Ledeganck KJ, Boulet GA, Horvath CA, et al. Expression of renal distal tubule transporters TRPM6 and NCC in a rat model of cyclosporine nephrotoxicity and effect of EGF treatment. Am J Physiol Renal Physiol 2011; 301:F486.
  22. Snyder RW, Berns JS. Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease. Semin Dial 2004; 17:365.
  23. Woodward RS, Flore MC, Machnicki G, Brennan DC. The long-term outcomes and costs of diabetes mellitus among renal transplant recipients: tacrolimus versus cyclosporine. Value Health 2011; 14:443.
  24. Woodward RS, Schnitzler MA, Baty J, et al. Incidence and cost of new onset diabetes mellitus among U.S. wait-listed and transplanted renal allograft recipients. Am J Transplant 2003; 3:590.
  25. Wilkinson A, Davidson J, Dotta F, et al. Guidelines for the treatment and management of new-onset diabetes after transplantation. Clin Transplant 2005; 19:291.
  26. Boots JM, Christiaans MH, Van Duijnhoven EM, et al. Early steroid withdrawal in renal transplantation with tacrolimus dual therapy: a pilot study. Transplantation 2002; 74:1703.
  27. Briggs JD. Causes of death after renal transplantation. Nephrol Dial Transplant 2001; 16:1545.
  28. Screening of donor and recipient prior to solid organ transplantation. Am J Transplant 2004; 4 Suppl 10:10.
  29. Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601.
  30. Winston DJ, Emmanouilides C, Busuttil RW. Infections in liver transplant recipients. Clin Infect Dis 1995; 21:1077.
  31. The AST Infectious Disease Community of Practice, Amercian Society of Transplantation, Infectious Disease Guidelines for Transplantation. Am J Transpl 2009; 9 (Suppl 4):S1.
  32. Mix TC, Kazmi W, Khan S, et al. Anemia: a continuing problem following kidney transplantation. Am J Transplant 2003; 3:1426.
  33. Ganz T. Hepcidin, a key regulator of iron metabolism and mediator of anemia of inflammation. Blood 2003; 102:783.
  34. Lee P, Peng H, Gelbart T, et al. Regulation of hepcidin transcription by interleukin-1 and interleukin-6. Proc Natl Acad Sci U S A 2005; 102:1906.
  35. Sun CH, Ward HJ, Paul WL, et al. Serum erythropoietin levels after renal transplantation. N Engl J Med 1989; 321:151.
  36. Shah N, Al-Khoury S, Afzali B, et al. Posttransplantation anemia in adult renal allograft recipients: prevalence and predictors. Transplantation 2006; 81:1112.
  37. Afzali B, Al-Khoury S, Shah N, et al. Anemia after renal transplantation. Am J Kidney Dis 2006; 48:519.
  38. Chadban SJ, Baines L, Polkinghorne K, et al. Anemia after kidney transplantation is not completely explained by reduced kidney function. Am J Kidney Dis 2007; 49:301.
  39. Ojo AO, Hanson JA, Wolfe RA, et al. Long-term survival in renal transplant recipients with graft function. Kidney Int 2000; 57:307.
  40. U.S. Renal Data System: USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease, 2007.
  41. USRDS: Annual Data Report: Atlas of End Stage Renal Disease in the United States, Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005.
  42. Kasiske BL, Guijarro C, Massy ZA, et al. Cardiovascular disease after renal transplantation. J Am Soc Nephrol 1996; 7:158.
  43. Aakhus S, Dahl K, Wideroe TE. Cardiovascular morbidity and mortality in renal transplant recipients. Nephrol Dial Transplant 1997; 12:A231.
  44. Boots JM, Christiaans MH, van Hooff JP. Effect of immunosuppressive agents on long-term survival of renal transplant recipients: focus on the cardiovascular risk. Drugs 2004; 64:2047.
  45. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42:1206.
  46. Kasiske BL, Anjum S, Shah R, et al. Hypertension after kidney transplantation. Am J Kidney Dis 2004; 43:1071.
  47. Opelz G, Wujciak T, Ritz E. Association of chronic kidney graft failure with recipient blood pressure. Collaborative Transplant Study. Kidney Int 1998; 53:217.
  48. Wissing KM, Abramowicz D, Broeders N, Vereerstraeten P. Hypercholesterolemia is associated with increased kidney graft loss caused by chronic rejection in male patients with previous acute rejection. Transplantation 2000; 70:464.
  49. Kasiske BL, K/DOQI Dyslipidemia Work Group. Clinical practice guidelines for managing dyslipidemias in kidney transplant patients. Am J Transplant 2005; 5:1576.
  50. Gore JL, Pham PT, Danovitch GM, et al. Obesity and outcome following renal transplantation. Am J Transplant 2006; 6:357.
  51. Barbaro D, Orsini P, Pallini S, et al. Obesity in transplant patients: case report showing interference of orlistat with absorption of cyclosporine and review of literature. Endocr Pract 2002; 8:124.
  52. Ernst E. St John's Wort supplements endanger the success of organ transplantation. Arch Surg 2002; 137:316.
  53. Kasiske BL, Snyder JJ, Gilbertson DT, Wang C. Cancer after kidney transplantation in the United States. Am J Transplant 2004; 4:905.
  54. Vajdic CM, McDonald SP, McCredie MR, et al. Cancer incidence before and after kidney transplantation. JAMA 2006; 296:2823.
  55. Wong G, Chapman JR, Craig JC. Cancer screening in renal transplant recipients: what is the evidence? Clin J Am Soc Nephrol 2008; 3 Suppl 2:S87.
  56. EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.6.2. Cancer risk after renal transplantation. Skin cancers: prevention and treatment. Nephrol Dial Transplant 2002; 17 Suppl 4:31.
  57. McKay DB, Josephson MA. Pregnancy after kidney transplantation. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S117.
  58. Davison JM. Dialysis, transplantation, and pregnancy. Am J Kidney Dis 1991; 17:127.
  59. First MR, Combs CA, Weiskittel P, Miodovnik M. Lack of effect of pregnancy on renal allograft survival or function. Transplantation 1995; 59:472.
  60. Akbari F, Alavi M, Esteghamati A, et al. Effect of renal transplantation on sperm quality and sex hormone levels. BJU Int 2003; 92:281.
  61. McKay DB, Josephson MA, Armenti VT, et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005; 5:1592.
  62. EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.10. Pregnancy in renal transplant recipients. Nephrol Dial Transplant 2002; 17 Suppl 4:50.