Kidney Transplantation: A Guide to the Care of Kidney Transplant Recipients
Beschreibung
Kidney Transplantation: A Guide to the Care of Transplant Recipients is an easy to read, up to date, clinical resource written by experts in the field of kidney transplantation. The book explains how donors and recipients are selected for transplantation, how the surgical procedure is performed, and how the experts recognize and treat rejection.
Clearly illustrated chapters show how the immune system works in the setting of transplantation and how immunosuppressive medications prevent rejection of the transplanted kidney; knowledge essential for the proper care of the transplant recipient.
The acute and long-term care of the patient is described from the perspective not only of proper immunosuppressive medication management, but also from the perspective of comorbidities most common to transplanted patients, including cardiovascular disease, diabetes mellitus, infectious diseases, malignancies, and bone disease. Special issues that impact the care of the transplant recipient, such as unusual donor sources, nonadherence and insurability are also addressed.
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Alexander C. Wiseman and James E. Cooper
Rationale for Optimizing Current Immunosuppressant Strategies
While short-term outcomes in kidney transplantation have improved significantly over the last decades, questions remain regarding long-term improvements in graft survival. Whereas long-term graft survival was reported to improve significantly from the mid-1980s to the mid-1990s,1 a more recent analysis has shown an equivalent relative risk of graft failure for those transplanted in 1995 through 2000 despite a reduction in acute rejection rates of nearly 50% during that time.
Thus, attention has shifted to medication regimens that not only prevent early acute rejection but also take into consideration drug side-effect profiles, ease of use, and effect on long-term graft function. One potentially modifiable factor in improving long-term graft function is the avoidance of nephrotoxicity caused by calcineurin inhibitors (CNIs). CNI nephrotoxicity may be present in 33% of protocol biopsies at 1 year and nearly 100% of all biopsies at 10 years.
Recipients of non-kidney solid organ transplants are not exempt from CNI nephrotoxicity, as over 90% of liver, heart, and lung transplant patients remain on CNI at 1 year,4 with rates of chronic kidney disease (GFR < 30ml/min) of 10–20% over the long term.5 In addition to their nephrotoxic effects, CNIs are associated with post-transplant diabetes, hypertension, hyperlipidemia, hirsutism, neurotoxicity, and alopecia. With the development of newer agents, considerable effort has been devoted to safely reducing exposure of kidney transplant recipients to CNIs over the last decade.
While steroids have not been implicated in chronic graft loss, they are associated with numerous complications that have significant effects on patient morbidity and dissatisfaction. As with CNIs, steroid use causes hypertension and hyperlipidemia, but can also result in obesity, glucose intolerance, osteonecrosis, avascular necrosis, glaucoma, cataracts, myopathy, cushingoid features, and neuropsychiatric complications. An economic analysis of chronic steroid therapy in kidney transplant recipients estimated a $5,300 cost per patient year in 1996,6 concluding that elimination of steroids from immunosuppressive regimens would be cost equivalent even if associated with an 11% increase in acute rejection rates.
Importantly, patients perceive steroids to be less desirable than CNIs and if given an option to discontinue one medication, 65% would prefer steroid elimination vs. 19% that would prefer CNI elimination.7 The metabolic, cardiovascular, and cosmetic side effects associated with chronic corticosteroid use have inspired numerous trials to limit their use. Figure 10.2 illustrates common side effects encountered with chronic steroid and CNI use."
