Essentials of Diagnosis
The demographic of kidney transplant candidates and recipients has increasingly shifted toward older patients with the greatest growth among recipients between 45 and 65 years of age, and especially those with a history of diabetes or hypertension. Many of these recipient candidates are frail and require a more comprehensive pretransplant evaluation to determine the appropriateness of proceeding with transplantation.
Tacrolimus remains the backbone of the most commonly used immunosuppressive regimen in the United States, however, the novel intravenous costimulation blocking drug belatacept is associated with higher GFRs compared with cyclosporine. It is anticipated that allograft survival will be prolonged by belatacept as this drug is not associated with development of interstitial fibrosis and tubular atrophy in kidney transplants.
The incidence and burden of malignancy development in immunosuppressed kidney transplants in increasingly a concern. It is imperative that healthcare professions caring for transplant recipients not overlook the need to continue age appropriate cancer screening.
Recurrent disease remains a cause of premature allograft failure following kidney transplantation. Efforts to further characterize the putative soluble “circulating permeability factor” of FSGS have thus far been unsuccessful while C3 glomerulonephritis is associated with a high rate of recurrence and allograft loss following kidney transplantation.
The decision to discontinue immunosuppression following kidney transplant failure when subsequent retransplantation is expected remains controversial. While the data indicate that survival on dialysis off immunosuppression is increased, patients who have had their immunosuppression withdrawn may be at increased risk of becoming sensitized, making identification of a subsequent compatible donor more challenging.
Approximately 4.5 million individuals were diagnosed with chronic kidney disease (CKD) in the United States in 2014. While the majority of this group will either not progress to end stage kidney disease (ESRD), or die secondary to an etiology other than ESRD, over 100,000 individuals start on renal replacement annually. When confronted with the need for replacement therapy, affected patients have three major options to consider: hemodialysis, peritoneal dialysis, and kidney transplantation. Of course, the decision not to pursue replacement therapy is the remaining option that should always be offered and discussed with patients, particularly those who are elderly or suspected of having a low quality of life.
Kidney transplantation is a field unto itself. No single textbook, let alone single textbook chapter, can possibly cover all aspects of this complex topic. This chapter focuses on those features of kidney transplantation that a general nephrologist should be well versed and prepared to discuss with a recipient, or recipient candidate, they find under their care.
Hemodialysis and peritoneal dialysis are two options that are life-saving in ESRD patients. However, neither fully replaces the metabolic and hormonal functions of the kidney and both the length and quality of life for patients undergoing treatment was arguably rather poor. This challenged the medical profession to find a superior form of renal replacement therapy. While the concept of organ transplantation dates as far back ...