Kidney Transplantation and Immunosuppression
Core concepts
Kidney transplantation is the preferred treatment for children with end-stage kidney disease because it improves survival, growth, and quality of life. Pretransplant evaluation includes HLA typing, crossmatching, viral serologies, cardiac and urologic assessment, and vaccination. Induction therapy reduces early rejection; maintenance immunosuppression commonly includes a calcineurin inhibitor (tacrolimus or cyclosporine), an antimetabolite (mycophenolate), and steroids. Rejection may be hyperacute, acute cellular, or antibody-mediated. Infections include CMV, Epstein-Barr virus, BK virus, and urinary tract infections. Calcineurin inhibitors are nephrotoxic and require trough monitoring.
Traps
A rising creatinine after transplant may be rejection, drug toxicity, infection, obstruction, or recurrence of the original disease; biopsy is often needed. Do not adjust immunosuppression blindly. BK nephropathy can mimic rejection. Live vaccines are contraindicated during significant immunosuppression. Calcineurin inhibitors interact with many drugs, including azoles and macrolides. Mycophenolate is teratogenic. Recurrence of FSGS can occur.
Worked example / rule of thumb
A transplant recipient with fever, graft tenderness, and rising creatinine should undergo urgent evaluation and often biopsy before empiric changes. Rule: check tacrolimus trough and drug interactions whenever creatinine rises; do not assume rejection without excluding infection, obstruction, and toxicity.