Long-Term Monitoring and Care of the Kidney Transplant Recipient

Andrew Howard, MD

Disclosures

July 12, 2004

Since the advent of new immunosuppressive therapies, kidney transplantation has become a highly successful procedure that provides reasonable expectation of long-term graft and patient survival. Nonetheless, kidney transplant recipients must be diligently monitored in order to ensure the health of the transplanted kidney and to guard against complications of transplantation and immunosuppressive therapy.

While the primary means of assessing renal function has been the measurement of serum creatinine (SCr) levels, the use of glomerular filtration rate (GFR) prediction equations will provide an invaluable tool to more accurately quantitate posttransplant renal function.[1] The most commonly employed formula for assessing GFR in chronic kidney disease, a condition affecting a majority of transplant patients, is the Modification of Diet in Renal Disease Study Group equation using SCr, age, sex, and race.[1] Transplant renal biopsy may be required in certain cases and should be discussed by the community nephrologist with the transplant center and performed where adequate histologic interpretation of the specimen can be assured.[2] A timetable for additional recommended tests is provided in Table 1 .[2]

The community nephrologist should also monitor blood levels of immunosuppressant drugs in order to ensure that the patient is receiving sufficient therapy and that levels are not high enough to cause nephrotoxicity. Calcineurin inhibitors (CNIs) such as tacrolimus (TAC) and cyclosporine (CsA) are a component of almost all immunosuppressive regimens, and their levels must be monitored closely, especially in the first year after transplantation. This is important because CNIs have a narrow therapeutic index and nephrotoxicity can be difficult to distinguish from rejection episodes.[3,4] After the first month, TAC should be maintained at blood trough levels of 5 to 12 ng/mL, and cyclosporine trough levels should be maintained at 135 to 370 ng/mL.

As always, good communication between the community nephrologist and the transplant center is pivotal to effective monitoring of the kidney transplant patient and to providing the most appropriate care. The community nephrologist should contact the transplant center if acute or chronic rejection or malignancy is suspected, or if there is an unexplained change in serum creatinine levels.[2] Likewise, the transplant center should provide the community nephrologist with all information necessary to interpret and schedule tests ( Table 2 ).

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