Causes of late renal allograft loss: chronic allograft dysfunction, death, and other factors.

CAN and patient death with allograft function are the 2 major causes of renal allograft loss after the first year, accounting for 80% or more of cases. According to current estimates from the United Network for Organ Sharing (UNOS), the half-lives for renal allografts performed in 1995 and 1996 from living and cadaveric donors are 15.3 and 10.4 years, respectively (2). Consequently, much attention has been focused on better understanding the causes of CAN and patient death with a functioning allograft in an attempt to improve long-term renal allograft outcomes. Although the pathogenesis of CAN is not completely understood, we know that CAN involves alloantigen-dependent and alloantigen-independent factors that combine to produce chronic deterioration of renal allograft function. CVD is the most frequent cause of death in renal transplant recipients, and we need to address its well-established risk factors in that population. Among other improvements, changes in current immunosuppressive protocols may increase long-term renal allograft survival and function by decreasing both the risk of CAN and the risk of CVD.

Azathioprine withdrawal in renal transplant recipients. A long-term follow-up.

Azathioprine (AZTP) must sometimes be discontinued in cadaveric kidney recipients. Long-term survival of patients after AZTP withdrawal is questionable, and many groups consider that maintenance treatment with AZTP is preferable to its discontinuation despite potential severe side effects. In our group AZTP had to be discontinued in 39 recipients of first renal allografts (30 cadaver kidney recipients, 9 living-related recipients) because of severe liver disease or cancer. The median follow-up period after AZTP withdrawal was 32 months, ranging from 5 to 84 months. Deterioration of renal function, which occurred in 11 (28.2%) patients, was more frequently observed in recipients of an incompatible graft (2-4 HLA-A and B mismatches (P = 0.02)). The graft survival rate of 56.9% at 10 years for the whole group of patients compares favorably with the 63.2% graft survival rate of a matched control group of 79 patients. Thus, AZTP may be discontinued whenever required without increasing the rate of graft loss.

KDIGO clinical practice guideline for the care of kidney transplant recipients: a summary

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression and graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research. This summary includes a brief description of methodology and the complete guideline recommendations but does not include the rationale and references for each recommendation, which are published elsewhere.