Long-term issues in renal transplant recipients

The three commonest causes for death in transplant recipients are cardiovascular disease, malignancy and infection.

Cardiovascular disease

There is obviously a pre-transplant cardiovascular disease burden in association with CKD and particular dialysis-dependent ESRD, but there is also an increased risk from immunosuppressive medications e.g. prednisolone and Tacrolimus are associated with hypertension and hyperglycaemia. Obviously modification of the standard cardiovascular risk factors is important in this population.

Malignancy

The malignancy risk increases with the cumulative dose of immunosuppression and in those who have survived for at least 20 years with a functioning transplant, it is the leading cause of death thereafter. The commonest malignancy is skin cancer, and in this population such cancers can be aggressive, invasive and be the cause of death. Opportunity should be taken at any encounter to re-enforce advice regarding sun protection and prescription of sunscreen with a SPF of >50 may be helpful. Transplant recipients should be strongly encouraged to avail of the national screening programmes, but there is no recommendation for increased frequency of screening.

Infection

The infection risk is highest early in the transplant course when the patient is on maximal immunosuppression, or following enhanced immunosuppression to treat rejection. However, it is crucial to know that even those on lower doses of immunosuppression, years after transplantation, can get ill very quickly with infection. There should be a lower threshold for hospitalisation, and for a longer course of oral antibiotic therapy than would be given to a non-immunosuppressed individual.  Occasionally immunosuppression medication needs to be reduced, but this is only in severe infection when the patient requires hospitalisation and under the direction of the transplant team.

The goal is to have transplant patients on the minimum effective dose of immunosuppression, i.e. just enough to stop rejection. Sadly our tools to predict just how much immunosuppression is needed for any individual are crude and imprecise. It is a mix of art and science in immunosuppression reduction, but this is the key to the long term survival of the patient.