Transplantation of the kidney

Abstract

It is convenient to examine the problem of deteriorating renal function over time, since the differential and focus of the workup change from the early period (days 0-7), through the intermediate period (day 8 to 3 months), and the late period (over 3 months). Throughout this time course, rejection of some kind is always a consideration; the early period is associated with antibody mediated rejection (hyperacute rejection and accelerated rejection), and the intermediate period is dominated by cellular-mediated rejection, and the late period is associated with chronic rejection. Rejection as a cause for graft loss has been minimized by the present-day armamentarium of immunosuppressive drugs. The penalty that is paid for this benefit, however, is that, as time progresses, the nephrotoxicities associated with the immunosuppressive drugs play a dominant role in allograft dysfunction. In addition, drugs that alter the metabolism of these immunosuppressive agents, as well as medications that act synergistically with them to cause nephrotoxicity, need to be monitored closely once the patient leaves the acute care setting. Finally, in the late period, the cause of renal dysfunction is further complicated by the possibility of recurrent renal disease as well as de novo renal disease. The investigation into renal allograft dysfunction often is aided by routine laboratory tests, urinalysis, complete metabolic panel, complete blood count, and immunosuppressive drug levels; ultimately, however, a renal biopsy often is required for the definitive answer. © Springer Science+Business Media, Inc. 2005.