A Report of the Lisbon Conference on the Care of the Kidney Transplant Recipient

An International Conference on the Care of the Kidney Transplant Recipient was convened in Lisbon, Portugal from February 2–4, 2006 under the auspices of the National Kidney Foundation and Kidney Disease: Improving Global Outcomes (KDIGO), and in cooperation with The Transplantation Society. Conference participants included over 100 experts and leaders in kidney transplantation, representing more than 40 countries from around the world, including participants from Africa, Asia, Australia, Europe, North American, and South America (Appendix). The goal of the conference was to develop recommendations to improve the outcomes of kidney transplant recipients worldwide with regard to the following basic medical issues: cardiovascular disease (Work Group I), cancer and infection (Work Group II), and anemia, bone disease, reproductive issues, growth and development (Work Group III). Work Groups I, II, and III addressed the preand posttransplant care of kidney transplant recipients by the following components: timelines of pre- and posttransplantation, immunosuppression, level of kidney allograft function, and burden of disease (prior history of dialysis or preemptive transplant and how that history affects outcome). A graft maintenance section (Work Group IV) addressed: 1) recipient (and donor) selection; 2) surgical aspects and immediate posttransplant care of recipients including consideration of minimal surgical infrastructure; 3) immunosuppression including an assessment of the incremental expected value of more complex and expensive regimens in comparison to simpler and less expensive regimens, generics, mid- and long-term immunosuppression; 4) living donor versus deceased donor transplantation; and 5) mid- and long-term posttransplant care and monitoring of allograft function. In addition, conference participants were asked to examine the issue of applicability of the recently published Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines for chronic kidney disease (CKD) in kidney allograft recipients (1). Specifically, Work Group V addressed the role of estimated glomerular filtration rate (eGFR) in monitoring kidney function after transplantation, as well as the stratification for intervention according to eGFR values. Work Group I: Cardiovascular Disease Bertram Kasiske, Gabriel Danovitch, and Fernando Cosio: Co-Chairs Chronic kidney disease, before and after transplantation, is an independent risk factor for cardiovascular disease (CVD). Risk for CVD should be managed from the earliest stages of CKD. Although the absolute risk increases with age (2–5), the highest relative risk of CVD is in young adults with CKD. Prevention of CVD includes risk factor management and education (professionals and patients). Kidney transplantation provides a better outcome than dialysis, including less occurrence of CVD and a lower cost (6–8). Preemptive transplantation may also help to prevent CVD, and is now best accomplished with a living donor. Rationale for Assessing CVD Risk in Transplant Candidates The risk of CVD should be assessed for all potential transplant recipients to maximize safety and informed consent in transplantation and to prevent CVD events. Optimizing graft function may reduce CVD risk. This risk assessment will also optimize the utilization of scarce resources and determine the appropriate level of expertise needed for the transplantation. Pretransplant CVD evaluation Assessment should include a history and physical examination to detect symptomatic disease, and an electrocardiogram (ECG). Evaluation of asymptomatic patients at highest-risk for CVD events (defined below) may include noninvasive and/or invasive testing such as a coronary angiography, depending on local expertise and availability. However, there are no data establishing that screening of asymptomatic patients in itself prevents CVD events (9). Highest-risk patients are those with the following conditions: Diabetes (2–5) Prior CVD (5, 10–12) Multiple CVD risk factors, such as more than 1 year on dialysis (13); left ventricular hypertrophy (LVH) (14); age >60 years; smoking (2, 4, 15, 16); hypertension (3, 11, 17); and dyslipidemias (4, 10, 11) Highest-risk patients may still benefit from undergoing kidney transplantation. If there is an anticipated wait of over 2 years for transplantation, then assessment of CVD should be repeated annually in high- risk individuals. (18, 19). Perioperative Management The perioperative period is a time for CVD events, especially for high-risk patients. Perioperative beta-blockade is strongly recommended for these transplant candidates to prevent perioperative CVD events and should be started, whenever possible, at least 1 month prior to surgery (20, 21). Patients not on a beta-blocker immediately before surgery should be assessed for intravenous beta-blockade. Low-dose aspirin prophylaxis in the pretransplant period is not a contraindication to transplantation (22). Posttransplant Management CVD is a major cause of morbidity and premature mortality after transplantation. Death with a functioning graft in the immediate posttransplant period is often caused by CVD. Posttransplant care should include ongoing CVD risk factor management with a special focus on hypertension, dyslipidemia, and diabetes. Hypertension Hypertension should be managed according to existing guidelines for CKD patients (23). Target blood pressure should be <130/80 mm Hg (and probably lower in patients with persistent proteinuria). All classes of antihypertensive agents can be used in transplant recipients and no single class has to be to after kidney transplantation. should be of potential in kidney transplant are and with the of antihypertensive classes in kidney transplant is after transplantation, often a the can cause an in that are and in kidney transplant may to may blood of and a of A may be by the cost of and are also antihypertensive agents in kidney transplant may to anemia, and cause an in that evaluation to kidney allograft are in transplant and may be in patients with coronary and agents are also in transplant a of agents is needed to blood blood pressure be with consideration should be to graft or of the the In addition, the may to hypertension blood pressure is to consideration should be to kidney should be managed according to existing guidelines for CKD patients are to prevent the occurrence of that are can cause If are is then patients should be with a If is are and is then patients should also be transplant patients with is to for 2 to before a However, the in that can be with and is in patients be expected reduce to by a should be with there is no of are the of in the of should be of potential in kidney transplant The of should be in patients with increases the blood of The of agents that and blood such as and should a or of the If and a are not to a then a can be should not be used in with a to the risk of the best of a is the Diabetes Diabetes should be managed according to existing guidelines may be to after transplantation. of after kidney transplantation is to of in the agents are The can be used after transplantation, may be with and is an for blood in the and has in clinical to reduce the of from diabetes. 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