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Overview of care of the adult kidney transplant recipient

Anil Chandraker, MD, FASN, FRCP
Melissa Y Yeung, MD, FRCPC
Section Editor
Daniel C Brennan, MD, FACP
Deputy Editor
Albert Q Lam, MD


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 the care of transplant recipients for the life of the graft, this is often not practical. However, communication between the internist or community-based nephrologist and the transplant center is important for optimal care of the patient.

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 "Cyclosporine and tacrolimus nephrotoxicity" and "Pharmacology of cyclosporine and tacrolimus", section on 'Side effects' and "Infection in the solid organ transplant recipient" and "Differential diagnosis of infection following renal transplantation" and "Clinical manifestations, diagnosis, and management of cytomegalovirus disease in kidney transplant recipients" and "Clinical manifestations and diagnosis of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation" and "Hepatitis B virus infection in renal transplant recipients" and "Hepatitis C infection in kidney transplant candidates and recipients" and "Epidemiology, clinical manifestations, and diagnosis of post-transplant lymphoproliferative disorders" and "Hypertension after renal transplantation" and "Lipid abnormalities after renal transplantation" and "New-onset diabetes after transplant (NODAT) in renal transplant recipients" and "Persistent hyperparathyroidism after renal transplantation" and "Bone disease after renal transplantation" and "Anemia and the renal transplant recipient" and "Erythrocytosis following renal transplantation" and "Development of malignancy following solid organ transplantation" and "Hyperuricemia and gout in renal transplant recipients".)

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Literature review current through: Nov 2017. | This topic last updated: Jun 30, 2017.
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  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. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009; 9 Suppl 3:S1.
  6. Hohage H, Kleyer U, Brückner D, et al. Influence of proteinuria on long-term transplant survival in kidney transplant recipients. Nephron 1997; 75:160.
  7. 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.
  8. 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.
  9. 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.
  10. Schwarz A, Gwinner W, Hiss M, et al. Safety and adequacy of renal transplant protocol biopsies. Am J Transplant 2005; 5:1992.
  11. Hart A, Smith JM, Skeans MA, et al. Kidney. Am J Transplant 2016; 16 Suppl 2:11.
  12. 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.
  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. Briggs JD. Causes of death after renal transplantation. Nephrol Dial Transplant 2001; 16:1545.
  16. The AST Infectious Disease Community of Practice, Amercian Society of Transplantation, Infectious Disease Guidelines for Transplantation. Am J Transpl 2009; 9 (Suppl 4):S1.
  17. Screening of donor and recipient prior to solid organ transplantation. Am J Transplant 2004; 4 Suppl 10:10.
  18. Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601.
  19. Winston DJ, Emmanouilides C, Busuttil RW. Infections in liver transplant recipients. Clin Infect Dis 1995; 21:1077.
  20. Ojo AO, Hanson JA, Wolfe RA, et al. Long-term survival in renal transplant recipients with graft function. Kidney Int 2000; 57:307.
  21. 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.
  22. 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.
  23. Kasiske BL, Guijarro C, Massy ZA, et al. Cardiovascular disease after renal transplantation. J Am Soc Nephrol 1996; 7:158.
  24. Aakhus S, Dahl K, Wideroe TE. Cardiovascular morbidity and mortality in renal transplant recipients. Nephrol Dial Transplant 1997; 12:A231.
  25. Yeo FE, Villines TC, Bucci JR, et al. Cardiovascular risk in stage 4 and 5 nephropathy. Adv Chronic Kidney Dis 2004; 11:116.
  26. Ojo AO. Cardiovascular complications after renal transplantation and their prevention. Transplantation 2006; 82:603.
  27. 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.
  28. Kasiske BL, Anjum S, Shah R, et al. Hypertension after kidney transplantation. Am J Kidney Dis 2004; 43:1071.
  29. Opelz G, Wujciak T, Ritz E. Association of chronic kidney graft failure with recipient blood pressure. Collaborative Transplant Study. Kidney Int 1998; 53:217.
  30. 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.
  31. Gore JL, Pham PT, Danovitch GM, et al. Obesity and outcome following renal transplantation. Am J Transplant 2006; 6:357.
  32. 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.
  33. Ernst E. St John's Wort supplements endanger the success of organ transplantation. Arch Surg 2002; 137:316.
  34. Golomb I, Winkler J, Ben-Yakov A, et al. Laparoscopic sleeve gastrectomy as a weight reduction strategy in obese patients after kidney transplantation. Am J Transplant 2014; 14:2384.
  35. Modanlou KA, Muthyala U, Xiao H, et al. Bariatric surgery among kidney transplant candidates and recipients: analysis of the United States renal data system and literature review. Transplantation 2009; 87:1167.
  36. Szomstein S, Rojas R, Rosenthal RJ. Outcomes of laparoscopic bariatric surgery after renal transplant. Obes Surg 2010; 20:383.
  37. Troxell ML, Houghton DC, Hawkey M, et al. Enteric oxalate nephropathy in the renal allograft: an underrecognized complication of bariatric surgery. Am J Transplant 2013; 13:501.
  38. Rankin AC, Walsh SB, Summers SA, et al. Acute oxalate nephropathy causing late renal transplant dysfunction due to enteric hyperoxaluria. Am J Transplant 2008; 8:1755.
  39. 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.
  40. 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.
  41. 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.
  42. 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.
  43. Hartmann EL, Gatesman M, Roskopf-Somerville J, et al. Management of leukopenia in kidney and pancreas transplant recipients. Clin Transplant 2008; 22:822.
  44. Kotton CN, Fishman JA. Viral infection in the renal transplant recipient. J Am Soc Nephrol 2005; 16:1758.
  45. Yabu JM, Winkelmayer WC. Posttransplantation anemia: mechanisms and management. Clin J Am Soc Nephrol 2011; 6:1794.
  46. Vanrenterghem Y, Ponticelli C, Morales JM, et al. Prevalence and management of anemia in renal transplant recipients: a European survey. Am J Transplant 2003; 3:835.
  47. Mix TC, Kazmi W, Khan S, et al. Anemia: a continuing problem following kidney transplantation. Am J Transplant 2003; 3:1426.
  48. Ganz T. Hepcidin, a key regulator of iron metabolism and mediator of anemia of inflammation. Blood 2003; 102:783.
  49. 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.
  50. Sun CH, Ward HJ, Paul WL, et al. Serum erythropoietin levels after renal transplantation. N Engl J Med 1989; 321:151.
  51. Kasiske BL, Snyder JJ, Gilbertson DT, Wang C. Cancer after kidney transplantation in the United States. Am J Transplant 2004; 4:905.
  52. Vajdic CM, McDonald SP, McCredie MR, et al. Cancer incidence before and after kidney transplantation. JAMA 2006; 296:2823.
  53. Kasiske BL, Vazquez MA, Harmon WE, et al. Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation. J Am Soc Nephrol 2000; 11 Suppl 15:S1.
  54. 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.
  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. Osorio JM, Bravo J, Pérez A, et al. Magnesemia in renal transplant recipients: relation with immunosuppression and posttransplant diabetes. Transplant Proc 2010; 42:2910.
  57. 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.
  58. Falkiewicz K, Nahaczewska W, Boratynska M, et al. Tacrolimus decreases tubular phosphate wasting in renal allograft recipients. Transplant Proc 2003; 35:2213.
  59. Ambühl PM. Posttransplant metabolic acidosis: a neglected factor in renal transplantation? Curr Opin Nephrol Hypertens 2007; 16:379.
  60. Abbott KC, Kimmel PL, Dharnidharka V, et al. New-onset gout after kidney transplantation: incidence, risk factors and implications. Transplantation 2005; 80:1383.
  61. McKay DB, Josephson MA. Pregnancy after kidney transplantation. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S117.
  62. Davison JM. Dialysis, transplantation, and pregnancy. Am J Kidney Dis 1991; 17:127.
  63. First MR, Combs CA, Weiskittel P, Miodovnik M. Lack of effect of pregnancy on renal allograft survival or function. Transplantation 1995; 59:472.
  64. Akbari F, Alavi M, Esteghamati A, et al. Effect of renal transplantation on sperm quality and sex hormone levels. BJU Int 2003; 92:281.
  65. 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.
  66. 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.
  67. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.