Abstract
Kidney transplantation (KT) is the most effective way to decrease the high morbidity and mortality of patients with end-stage renal disease. However, KT does not completely reverse the damage done by years of decreased kidney function and dialysis. Furthermore, new offending agents (in particular, immunosuppression) added in the post-transplant period increase the risk of complications. Cardiovascular (CV) disease, the leading cause of death in KT recipients, warrants pre-transplant screening based on risk factors. Nevertheless, the screening methods currently used have many shortcomings and a perfect screening modality does not exist. Risk factor modification in the pre- and post-transplant periods is of paramount importance to decrease the rate of CV complications post-transplant, either by lifestyle modification (for example, diet, exercise, and smoking cessation) or by pharmacological means (for example, statins, anti-hyperglycemics, and so on). Post-transplantation diabetes mellitus (PTDM) is a major contributor to mortality in this patient population. Although tacrolimus is a major contributor to PTDM development, changes in immunosuppression are limited by the higher risk of rejection with other agents. Immunosuppression has also been implicated in higher risk of malignancy; therefore, proper cancer screening is needed. Cancer immunotherapy is drastically changing the way certain types of cancer are treated in the general population; however, its use post-transplant is limited by the risk of allograft rejection. As expected, higher risk of infections is also encountered in transplant recipients. When caring for KT recipients, special attention is needed in screening methods, preventive measures, and treatment of infection with BK virus and cytomegalovirus. Hepatitis C virus infection is common in transplant candidates and in the deceased donor pool; however, newly developed direct-acting antivirals have been proven safe and effective in the pre- and post-transplant periods. The most important and recent developments on complications following KT are reviewed in this article.
Highlights
End-stage renal disease (ESRD) is one of the leading causes of premature mortality, and the death rate for patients on dialysis is 166 per 1,000 patient-years[1]
Kidney transplant recipients still experience a high incidence of complications in the posttransplant period
calcium score (CACS) has been studied prospectively in two trials in kidney transplant candidates with conflicting results regarding the ability of CACS to predict major adverse cardiovascular events (MACE) and mortality in comparison with MPS37,38
Summary
End-stage renal disease (ESRD) is one of the leading causes of premature mortality, and the death rate for patients on dialysis is 166 per 1,000 patient-years[1]. CACS has been studied prospectively in two trials in kidney transplant candidates with conflicting results regarding the ability of CACS to predict MACE and mortality in comparison with MPS37,38 At this time, the CACS cannot be recommended as a first-line strategy for CV disease screening pre-kidney transplant. Coronary CT has good correlation with angiographic coronary disease[34,39], and an abnormal coronary CT is an independent risk factor for adverse CV outcomes in kidney transplant candidates[38,40] These results are from relatively small studies and require validation in larger trials with a more diverse population before the widespread use of coronary CT can be recommended as a CV disease screening method in renal transplant candidates. Coronary CT is solely a diagnostic modality and in the event of a positive test an invasive coronary angiography and angioplasty
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