Medical Complications of Renal Transplantation

With long-term function of allografts increasingly the norm, detection and management of medical complications assume greater importance in the care of renal transplantation recipients. At least two trends in transplantation seem likely to make medical surveillance even more crucial. First, better control of adverse immunologic events early after transplantation has significantly reduced graft loss caused by rejection; the impact of later events (especially death with a functioning organ and chronic rejection) on graft and patient survival is proportionately larger. Second, with successful transplantation now fairly routine, it is being offered to a broader spectrum of candidates, including increasingly older patients with multiple coexisting medical problems. Because more patients with immunosuppression are now being cared for over increasingly longer periods of time, the impact of comorbid events on outcomes must be reduced. Medical complications in the renal allograft recipient represent the often overlapping impact of several variables. At the time of transplantation, significant comorbidity may already be present and can be of immediate concern. Other problems may have originated in the milieu of chronic renal failure, such as hyperparathyroid bone disease or hypertension, but may evolve differently after transplantation. Finally, new complications may result from specific toxicities of pharmaceutical agents, reflecting the overall impact of immunosuppression. In many cases, all of these elements contribute to overt clinical illness. For instance, cardiovascular disease is now the most common cause of death in renal allograft recipients [1]. Coronary disease may have predated transplantation (indeed, coronary disease is a common cause of death among all patients with end-stage renal disease). After transplantation, hypertension and hyperlipidemia, perhaps exacerbated by administration of cyclosporine and corticosteroids, result in accelerated atherosclerosis, further potentiating preexisting cardiac problems. To intervene appropriately requires a comprehensive understanding of all the variables involved: any decision to lessen the impact of one risk factor (eg, withdrawing steroids) may result in unintended consequences (eg, acute rejection). Robert S. Gaston