I’ve heard that I might develop kidney problems after liver or heart transplantation. How can that happen?

Chronic renal failure is a recognized complication of all organ transplantation due to the need for immunosuppression. Both tacrolimus and cyclosporine can cause the kidneys to function less than optimally. Additionally, in patients with cirrhosis, heart disease, or renal disease before transplantation, the side effects of diuretic use, hypertension, and diabetes can all contribute to chronic renal failure in recipients of a new organ. Renal failure after the transplantation complicates medical management, leading to increased morbidity and mortality. The incidence of chronic renal disease among recipients of liver transplants is approximately 8% after 1 year, 14% after 3 years, and 18% after 5 years. For patients who have received a heart transplant, the incidence of chronic renal disease is 2% after 1 year, 7% after 3 years, and 11% after 5 years. This does not mean that all these patients need dialysis but rather that their kidneys are not fully functional. Some patients do, indeed, progress to dialysis; kidney transplantation may be indicated in these individuals.

A number of factors may predict the risk of developing renal failure, including age (older patients have a higher risk), gender (males have a higher risk than females), pretransplantation kidney function, and presence or absence of pretransplantation hypertension, diabetes, or hepatitis C infection. Overall, non-White, non-African American patients have the lowest risk of chronic renal failure.

Of course, most transplant recipients do not develop renal failure. For those with the risk factors mentioned previously, transplant physicians can work with them to reduce the risk of developing renal failure after organ transplantation. One technique is to reduce the dose of the primary immunosuppressive agent (that is, tacrolimus or cyclosporine). For those patients with a high risk or history of rejection, mycophenolate (CellCept, Myfortic) can be added to the drug regimen. A recent addition to the immunosuppression armamentarium, sirolimus (Rapamycin, Rapamune), can also reduce the risk. Sirolimus is not toxic to the kidneys and may be used for primary immunosuppression. This drug cannot be used immediately after organ transplantation because it slows wound healing; instead, it is typically prescribed later if concerns about renal dysfunction arise.