10 unanswered questions in kidney transplantation
In this article, we will describe 10 unanswered questions in kidney transplantation.
1. Why do blood clots in the transplanted kidney artery (and vein) still occur despite anticoagulation?
When blood in the blood vessels to the transplanted kidney clots, the kidney has no blood flow. It usually does not recover and has to be removed. We have few strategies to save such kidneys. Why?
2. Why does rejection of the kidney still occur despite modern immunosuppressive drugs?
The donated kidney may fail because of acute immune rejection. This is especially true in the first three months after a transplant. We still have imperfect protocols to prevent and treat it. Why?
3. Why does cancer still occur despite modern immunosuppressive drugs?
Cancer is still more common in transplant patients, especially lymphoma, Kaposi’s sarcoma, anogenital and skin cancers. Why care we not better at preventing it?
4. Why are we still unable to prevent heart attacks, heart failure and strokes in kidney transplant patients?
These atheromatous diseases are more common in transplant patients are, in part, thought to be due to the following point.
5. Why are we still unable to prevent and/or treat high blood pressure and high cholesterol in kidney transplant patients?
This is part of the reason heart attacks, heart failure and strokes are more common.
6. Why is the average life span of a kidney transplant still so low?
On average, it is 10 years for a deceased donor and 15 years for a living transplant. Hence many younger patients will need two or more transplants. Why cannot we make one kidney last a patient’s lifetime? More research needs to be done.
7. Why is transplant patient (not just kidney) survival also still not great?
Again, we don’t know. It may be due to damage to the heart before dialysis starts (or before the transplant, if you go straight to a transplant). We need strategies to improve it.
8. Why do we still prescribe nephrotoxic immunosuppression?
We continue to have the dilemma that tacrolimus and ciclosporin (mainstays of immunosuppression) are themselves nephrotoxic – and so toxic to the transplanted kidney. Better alternatives are required.
9. Why is donation of kidneys for transplantation still inadequate for the need?
There would be copious potential donors if we were willing to organise non-heart beating deceased donor transplantation. Xenotransplantation has been a research area for 30-40 years. It is still far from a clinical entity. Why? We need to make more effort to use available organs. New strategies are needed to improve transplant rates.
10. How do we reduce chronic transplant dysfunction and loss of kidneys?
Apart from controlling blood pressure and minimising nephrotoxic drugs, there are few specific therapies to prolong the life of a kidney transplant.
Summary
We have described 10 unanswered questions in kidney transplantation. We hope it has been interesting. There have been few huge advances since the 1990s. This is disappointing. Why not try to answer one of these questions?
Other resources
10 unanswered questions in CKD, nephrology and transplantation (linked article)
10 (more) unanswered questions in CKD, nephrology and transplantation (another linked article)
Long-term complications of renal transplantation (Bottomley, 2013)
Last Reviewed on 17 April 2024