Other risk factors

Although CNI exposure is the most important risk factor for developing CKD after NRSOT, multiple other factors contribute to the risk. These factors include hypertension (HTN), diabetes mellitus (DM), and acute kidney injury (AKI) prior to transplant.

Therefore, it is important for clinicians to strive for optimal control of HTN and DM after NRSOT. This is particularly relevant because almost 25% of recipients will develop DM after transplant22 and nearly 80% of patients will depend on medications to control their HTN. Targeting BP of 130/80 mm Hg or lower will hinder the progression of CKD.23

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Encouraging patients to exercise after transplant may be beneficial in controlling their DM and HTN and will encourage them to take ownership of their post-transplant care. Another simple but important modifiable, but less appreciated factor is that optimal control of lipids with statins might decrease the risk of CKD progression by decreasing inflammation.24,25

AKI before and early after transplantation has tremendous implications for recipient survival and the risk of developing CKD.26-29 However, clinicians should focus more on preventing AKI prior to transplantation. It seems clear that severe AKI requiring renal replacement may be required in up to 25% of NRSOT recipients and translates into a major risk for developing CKD in all NRSOT.6,30

Yet clinicians often fail to consider the impact of infection/sepsis, vasopressive medications, and antimicrobials on the development of AKI. AKI prevention should be considered one of the most important measures to lower CKD risk after NRSOT. This has become particularly important in liver transplants as the MELD scoring system for liver allocation favors potential recipients with renal dysfunction.


CKD after NRSOT is a growing problem with tremendous implication for our health care system. The success in preventing episodes of rejection has led to more recipients being able to enjoy long-term survival after transplant while unfortunately putting them at increased risk of CKD.

Until newer medications can be developed that prevent rejection without associated renal toxicity, clinicians need to rely on conservative measures to slow CKD progression. Further research into AKI biomarkers may be able to identify AKI at an earlier stage and ameliorate its negative effects on long-term renal function. Until then, nephrologists need to raise their awareness of AKI prevention prior to NRSOT. As the old adage goes, “an ounce of prevention is worth a pound of cure.”  

Dr. Hofmann is Associate Professor of Nephrology at the University of Wisconsin in Madison.


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