Despite the significant improvement in 1-year survival of transplanted kidneys, clinical kidney transplantation still faces significant challenges.
The two main areas are as follows.
1, donor shortage: With more and more patients willing to undergo kidney transplantation, the shortage of donor organs is increasingly becoming a worldwide problem limiting the development of kidney transplantation.
2. Chronic transplant nephropathy: Chronic failure of the transplant kidney is the most important factor in distant transplant renal failure, and because the etiology of chronic failure of the transplant kidney is multifaceted, the current tendency is to refer to it as chronic transplant nephropathy.
Chronic transplant nephropathy is the most common cause of distant graft failure, and the term chronic transplant nephropathy is used rather than chronic rejection because the etiology includes both immune and non-immune factors.
Chronic transplant nephropathy has the following clinical features.
1, mostly occurring more than 6 months after kidney transplantation
2. manifestations of chronic damage to the transplanted kidney, such as progressive urinary protein, hypertension, anemia and renal hypofunction
3, kidney biopsy suggests glomerulosclerosis and interstitial fibrosis.
Common causes of chronic transplant kidney nephropathy (with immune-related factors)
1, acute rejection: late rejection is more likely to trigger chronic transplant kidney nephropathy than early rejection.
2, histocompatibility mismatch: there is a significant correlation between the degree of donor-recipient HLA mismatch and the incidence of chronic transplant kidney nephropathy.
3, pre-sensitization: preoperative PRA positivity in transplant patients is more likely to lead to chronic transplant kidney nephropathy.
4, unreasonable immunosuppression program: postoperative immunosuppression intensity is not enough to lead to chronic rejection, while excessive immunosuppression can lead to CMV, B-KV and EBV and other viral infections, leading to viral infection-related nephropathy.
5, poor compliance with drug therapy: some patients have not developed good habits of taking medication, often missing medication, some patients due to economic reasons and even more due to fear of drug side effects, unauthorized reduction or even discontinuation of certain immunosuppressive drugs lead to insufficient immunosuppression caused by chronic transplant kidney nephropathy.
6, hepatitis C: there is increasing evidence that patients with hepatitis C after kidney transplantation often lead to chronic transplant nephropathy (hepatitis C-associated nephropathy).
Common causes of chronic transplant kidney nephropathy (non-immune related factors)
1, delayed graft function recovery: poor early graft kidney function recovery (DGF) in some patients after transplantation due to various reasons can cause an increased incidence of distant chronic graft nephropathy.
2, elderly donors: due to the declining renal function of elderly donors, the increased burden on the kidney after transplantation can lead to accelerated residual glomerulosclerosis triggering chronic transplant nephropathy.
3, donor-recipient weight mismatch: when the weight of the recipient exceeds the weight of the donor by more than 50%, it can lead to increased burden on the transplanted kidney triggering the decline of transplanted kidney function.
4, the nephrotoxicity of immunosuppressive drugs: the CNI class of drugs commonly used in clinical practice have nephrotoxic side effects, which can cause spasm of the small arteries of the transplanted kidney, leading to chronic transplant nephropathy with long-term application.
5, hyperlipidemia, hyperglycemia, hypertension, hyperuricemia: hyperlipidemia, hyperglycemia, hypertension can lead to transplanted kidney microangiopathy, resulting in transplanted kidney hypofunction.
6, infection: infection has long been thought to play a role in the development of systemic atherosclerosis.
7, smoking: smoking is another factor that has side effects on graft vasculopathy.
8, proteinuria: proteinuria can lead to tubulointerstitial damage and to kidney damage in chronic transplant nephropathy.
The causes of chronic transplant nephropathy are multifaceted, and many of them remain unknown to this day.
Prevention methods of chronic transplant nephropathy (a)
1, close follow-up, timely detection of early rejection reactions and drug-related kidney damage.
2.Strictly control blood transfusion before transplantation to avoid HLA antibody production.
3.Strictly take immunosuppressants on time and in the right amount.
4.Apply strong immunosuppressants to reduce the incidence of rejection reactions.
5.Prevent cytomegalovirus infection.
Prevention methods of chronic transplant kidney nephropathy (II)
1.If possible, try to reduce the dose of CsA and FK506.
2.Strictly control hypertension, hyperlipidemia, hyperglycemia and hyperuricemia.
3.Strict control of body weight.
4.Control the infection.
5.Control proteinuria.
6.Reduce the use of kidney-damaging drugs.
7. Quit bad habits and advocate healthy life.
Now, the 1-year survival rate of transplanted kidney has reached a very good level. With the progress of clinical and basic research of kidney transplantation, the development of high-efficiency and low-toxicity immunosuppressants and the enhancement of patients’ self-care awareness, we have reasons to believe that the long-term survival rate of transplanted kidney will be further improved.