A Report of the Lisbon Conference on the Care of the Kidney Transplant Recipient (2007)

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 and the level of for the CVD should a history and to disease, and an of for CVD may as a on and that of in CVD with the following CVD CVD risk as more than on dialysis age and may from kidney is an of over for transplantation, assessment of CVD should be in risk The is a for CVD for is for transplant to prevent CVD and should be to on a before should be assessed for in the is a to transplantation CVD is a of and after with a graft in the immediate posttransplant is by care should CVD risk factor management with a on and should be managed according to guidelines for should be (and lower in with of be in transplant recipients and to be to after kidney should be of potential in kidney transplant and with the of in kidney transplant is after transplantation, a the an in that and in kidney transplant may to may of and a of A may be by the cost of and also in kidney transplant may to anemia, and an in that to kidney allograft in transplant and may be in with and also in transplant a of is to be with consideration should be to graft or of the the In addition, the may to is to consideration should be to kidney should be managed according to guidelines for to prevent the occurrence of that is should be with a is and is should also be transplant with is to for to before a the in that be with and is in be expected reduce to by a should be with is of the of in the of should be of potential in kidney transplant The of should be in with increases the of The of that and as and should a or of the and a to a a be should be in with a to the risk of the best of a is the should be managed according to guidelines may be to after of after kidney transplantation is to of in the The be after transplantation, may be with and is an for in the and in clinical to reduce the of from in with kidney function. kidney transplant recipients to develop kidney to be in kidney transplant In the and with with of and A risk of after transplantation and is with risk for CVD all should be before transplantation on the risk for and following and of and of may reduce the risk for in should be managed according to guidelines for should be before and after kidney transplantation that and should be should be for the risk transplant should be and to and in of of graft function, is on may prevent CVD events. a of is the may be to and CVD risk of the is that CVD events. Work Group Recipient and and Co-Chairs was the with to the of of disease to the in is to the medical to be a donor. The on the care of the kidney donor addressed that posttransplant immunosuppression was with to for cancer and and for the of a risk of participants to the for a to all transplant that to on and This immediate to for of from of the of is that a be under the auspices of the on and Kidney In the is to that the issue under consideration is of that transplant should be that issue or in an of the that in a issue or is of and the is to that the issue or or is in or is by in to a of Care for the Recipient A medical history be on potential to a the and the potential to by risk for and is The and of for for also be A donor and in to a of Care for the Recipient for the donor is should be of the donor for to and II, disease, and and clinical of for should be a potential recipient is to in to of the Recipient assessment of the donor for to be in with and for Risk to the by for and kidney may be for of or for risk for for the infection is or or the of infection by an informed recipient the of from for recipients also to the of disease by to be and of disease be is a to that may after to and of and the risk of as an be and living a clinical history and and and to reduce the of of in the should be with as in may be in for deceased of reproductive age with to be for by A history of donor cancer the donor is disease or the cancer is with may be in that the The of a for recipients of from deceased for potential cancer donor is with in a to the transplant a of all deceased donor and and transplant in an of or potential donor cancer in recipients should be for cancer after and cancer in the living donor should be to the transplant on on the in to a of Care for and and for be the the will on the An and medical history history and also be or be to the of transplantation, as and in to a of Care for the donor is and should be with of infection should be for and and also a of the should kidney with should be with to and after transplantation, with with of infection should be for of the and on to disease should be assessed in and be for a history and to the risk of disease, and recommendations by the of Transplantation and the of potential recipients for with of should be in and and and should be may also be the of transplantation, the the was Kidney Transplantation for potential disease in be as as for transplantation and monitoring of the as should be for the following Kidney Transplantation after transplantation is less than to transplantation of after in is in and should be after transplantation and to to the of in the the following should be in transplant recipients A with to in Prevention and Recipient should reduce the risk of with the of on that in and infection kidney recipients should be for following and with risk of disease and should be or a preemptive in Recipient may preemptive or clinical on the immunosuppression and the risk of Disease with clinical disease be with and with a in the of The of Risk the of to well of immunosuppression The of disease is in the of Risk the of immunosuppression kidney transplant should for by or with or The of for will also a of infection by is in all and of infection is and adults with that to infection an to and of is more after transplantation the In from with of and in with of the should be by with to the of and of to prevent and of is to be addressed for following kidney transplantation to be to long-term outcomes with regimens posttransplant and with of the kidney transplant The for to be to before transplantation to be in the with that may be in be to transplantation, on dialysis transplant recipients should be after transplantation, transplant recipients should with recipients of a donor kidney a risk of and should be for the of should be for recipients on the of may be of from may be in recipients or under the recipient is in with informed consent and Recipient to recipients a clinical history and and and including the to reduce the of transplantation with should be for and risk for the development of a and for in with cancer in the should be for transplant with as and in a Recipient for Transplantation a of be for kidney transplantation the clinical of a cancer and transplantation to and the and in should be in all a of on the of cancer after transplantation with in and cancer may transplantation monitoring for Recipient A of should be for the development of recipient or cancer should be the and the as in the of a the of cancer after transplantation should be with the of to and of or in disease and and the of The of the immunosuppression should be in with cancer after transplantation, The following risk should be with to posttransplant in donor or recipient recipient disease recipient age and donor donor The following risk should be with to disease and recipient of immunosuppression with or or infection Work Group and and Co-Chairs or that Transplant care on or that as of the of of for after kidney is a of in the in and in disease In the for the of well and to be of Kidney in function, and be by the according to glomerular filtration rate stages to with The by to Work Group should be that the and an with a In a as a from is a the level of the development of as anemia, that be and guidelines to care on The of is a of in and in should a for to transplantation that 1) assessment for disease 2) 3) as or 4) 5) of as kidney disease, or and of to be in the and after to may be in the following a to following transplantation, in to the of The to for is the This level the of the of the for age and of all of the 1) 2) infection 3) 4) 5) of and The of should be to the of The level of to be with posttransplant is the and is to the is to the that the should be for allograft recipients may be to in the immediate for management may The that of the dialysis a of the kidney graft function, may be to chronic is the in level is more and the more than the is to be with in posttransplant is a risk factor for of in and Quality of function, and all to improve with that be by to in of chronic allograft affects a of allograft should be disease, and is that the be by or the is the is is Disease Kidney transplant recipients an risk with the and dialysis This is bone In the a bone is a for bone This is the in the transplant recipient The transplant recipient bone that bone in to in bone of is or to of of bone Although the with bone may an risk for the is that that to risk in transplant the of care should be to prevent bone the best bone disease is a Care be on the and as well as with and with bone with a history of of more for risk with that included or risk for posttransplant bone disease with a history of and more risk transplantation with a with and and with or that also for bone disease In the of a bone the of and history is also in risk a to or Risk of and should be following transplantation for the and the of the and should be and and the level is or a level is should guidelines for level of kidney function with be on is and The level should be a or level is with a history the for level to is posttransplant preemptive transplant to reduce with bone to for and to for to or to or as as for of posttransplant the with with with and for after to on growth a on of and and is by assessment and management should be in transplant and and in less than of bone age and growth should be in less than of should be on growth or to and The of growth is better by and The in is of growth in with is is to in the growth growth factor and The of growth in with on and and and the function also a growth is under the of and also a growth may to growth the of age and growth the of and transplantation; and of The of including preemptive may be to growth and clinical and In addition, is and on be by including of and and to improve growth of The of be by is a of on growth and in Kidney transplant the growth and may from growth and bone should be assessed and addressed before is be is for age and or is for age and The is in This be in before of the and should be of A of be with This to or with including the of and should be under is an for growth in with CKD. In posttransplant with stages to bone disease should be managed as bone guidelines a management be by by with a and growth is may the risk of should be before transplantation The may be after transplantation with the that should be to the transplant or surgical the risk of may be and may be may be less and the of to the risk for and as and less as should may be with more is in with kidney disease is after transplantation of age to and of of age for kidney disease, transplant immunosuppression, and The outcome of the for the and is by the level of kidney function and of the in of kidney transplant recipients with a of will a in of the the A over is with a in of The management is in before and age is to in transplant recipients may be by growth and anemia, and kidney function with function the outcome for the is with an of the of an is including a and an care is to a risk in transplant recipients in a an rate of the is with or and with the of risk is on the risk of with of is that be and The safety of to the risk of the to is the care of the the of transplant with care of with kidney disease, dialysis and The to basic care to a transplant recipient should the in and as by the following kidney transplantation in and with of function may as the of with the of and may following transplantation to the of after transplantation may also be to or The with is a of may be the is and of may also of or of with with should be with is to is The of is with an risk of infection may be a of on dialysis transplantation, of includes or to in transplant Work Group and Co-Chairs is now well that kidney transplantation is the of for with as better long-term and of to dialysis is also to be more cost than dialysis in the immediate transplant should be as a long-term Care of the recipient be for the of kidney allograft function, and kidney transplant should be on a to medical and of the transplant The following recommendations to the of a kidney transplant to transplantation, potential kidney transplant and living kidney to an and living and to in the and in the long-term following the transplant to deceased kidney to kidney function to a to the potential recipient and to the of or that the potential an risk. transplantation, recipients with to prevent of the transplantation, recipients by and to in allograft function a intervention is to and to and immunosuppression that is to prevent as to the risk for or from the The of is on kidney transplant is to the minimal to a kidney transplant under or may be to an kidney transplant with than and Recipient The of a versus deceased donor should the of to the donor and to the and the of the transplant in donor and deceased donor transplantation and management of living should the living donor recommendations a transplant deceased donor kidney transplantation, should with as over less than of and from infection or should be under transplant may to on young recipients to for age and be as Transplant should and the and to be with medical recommendations A of of the kidney disease surgical risk events. A to is should be for kidney transplantation an of recipient and donor and in the of is to a transplantation should be by with in and kidney should kidney transplantation is a risk of transplant donor or recipient as or disease, or or A An kidney disease that is to or kidney transplantation or Transplantation a or transplantation transplantation A that the potential to donor or recipient risk kidney transplantation a and and a and and donor and deceased donor transplantation; and to including a and an care The also the following and chronic dialysis, and an all and and and in kidney to medical including and in transplantation and with the management of kidney transplant to kidney and in disease, and should be all be in a should be to the transplant on a development and education should be for all of the transplantation and an with to and to outcomes should be is that the donor and recipient a and of and function of and and of the of to and and of a recipient a should be clinical assessment also be should be to potential and and cancer should be including a clinical and for the of and disease Work Group of the and function should be in were is with an of and and with with a history of or for with potential disease, an of and function should be of and with with should be is should be or a history of disease as well as for of as Work Group and for and should be or a history of disease, or maintenance education the of the transplant posttransplant and the for with and regimens, assessment of and and to following transplantation is that the transplant the to as of the and of and function and assessment of is for the to for assessment the to on of and kidney of the recipient is that the donor and recipient care the to a surgical and in transplantation a with for and surgical that with and the for Disease and Prevention of for allograft and monitoring of and infection and is that an surgical care to and recipients the to on the of in surgical in and and in or an the that is for and for and complex surgical to donor is that an surgical care to and recipients the to a surgical in from kidney for donor and of Care is that the donor and recipient care monitoring of and of to dialysis on in dialysis to and kidney to prevent and to of and of and posttransplant and and the of care in an is that the donor and recipient care to of or for of and to with in the management of posttransplant is for donor and recipient care to the for a of monitoring and of that posttransplant as and a transplant and the of a clinical as of the transplant be for the of allograft function. recipients will or or to prevent transplant of and and and in that be to immunosuppression from that in for kidney transplant In addition, will from a of or the of transplant to a A of a outcome a graft rate that regimens of a in with an and a regimens with or with regimens be in to clinical allograft allograft and Work participants the of a of and a for transplantation as a in a outcomes from and in than kidney transplantation from a were to be graft This was by for or deceased donor kidney transplantation in of the the of is for medical and to reduce by a The of by the to the more of including kidney transplantation, in is that the of and with the the of for is on the and of were by the of Transplantation conference on and the of as with the and of is that to the of in the as of a with the of the countries improve by that in the or a is to a in an that allograft function. The cost of of and or allograft that from the of that may well by to a that or in the of the of This to be in the of with of posttransplant and posttransplant Although is a long-term allograft from the of in the of in with is an that be in kidney transplant be to reduce the of in or for from graft function and of with the of may be as to to of In the posttransplant monitoring of the is to the and to the The of posttransplant is with better and of is that of and be as an for the of a kidney transplant of may also be is that transplant that to care by or should and the minimal for care of kidney transplant Kidney function be the of the graft for the of from disease, or chronic allograft and of and chronic kidney is that monitoring of allograft function should less than the the the and and the will more for monitoring should of and and should the and with is that all transplant to kidney on is to to transplant function as for of and with and is to the to and and of to posttransplant and long-term than after in and after the posttransplant includes the of the kidney allograft and the kidney function or the clinical of the recipient may be to the and of with a kidney transplant should be under the care of a and 5) and of clinical and the after kidney of the kidney transplant may the of or chronic allograft be the in kidney function in comparison to that the best level of kidney function the after may be as a in or more as or glomerular filtration rate or by on kidney A for the of allograft is a in of or a of the best level of kidney function following increases in may and on clinical also and intervention kidney function and may The and of in will be from and be to of allograft and to kidney function of chronic kidney transplant after the posttransplant to the of and to recommendations for and clinical is an of kidney transplant The and of to the monitoring of allograft function and the care of the prevent is to and maximize the of for of care and pre- and posttransplant and as is to a long-term and the recipient and the transplant including to a transplant and and to the of a is for the transplant to to the transplant and to monitoring as and is to to the of the and of on transplant and recipients is that transplant and allograft and for and of be medical to to on a for and and for and is for the and of and transplant that and posttransplant outcomes be and on a and that to and the Work Group Chronic Kidney Disease and the Kidney Transplant Recipient Co-Chairs A of the Kidney Disease: Improving Global Outcomes that all kidney transplant recipients should be to of or or of of kidney Work Group V to kidney transplantation is a a for kidney of by the kidney the burden to as in the of transplant recipients to the and the of dialysis to transplantation as an risk factor for graft and and the of kidney with the of kidney disease monitoring of allograft function of kidney transplant by following in care the of in and of kidney disease (1). in transplant to and in bone disease, that may be to intervention Work Group V that of should be the in posttransplant and is estimated by of to estimated in transplant recipients that eGFR more with disease burden and outcome after transplantation than to from with and The National Kidney Foundation on the of in Disease eGFR the be in with kidney function and in and that and may be less in transplant recipients than in the for of in than in to and in and of in the of and for in the care of kidney Work Group V and the of with to over In may be to with of age and or of or kidney function, to with that by the and (1). In the of the Work should also be in clinical in of allograft is and eGFR may be the of kidney function should also of In kidney transplant is an of and is with chronic or disease, transplant Although is a of kidney and a risk factor for of and cardiovascular disease in in transplant recipients is may be to kidney function, a of to transplant recipients also and and with in kidney as a of kidney function in transplant recipients may be Work Group V to from the guidelines by and by of is by of an and burden of disease in kidney In the the of and anemia, and to from in to in and also an independent and risk of graft the clinical for the management of Work Group V is that for stages to in should be in all kidney transplant The of to all with a transplant disease burden with also all for stages to of that transplant recipients with eGFR may graft function for for of dialysis or a transplant should by of in eGFR and This is on that rate of is may be in transplant and is by risk in A clinical on as by the on should be with the following with of The was by Kidney Disease: Improving Global Outcomes (KDIGO), a managed by the National Kidney Foundation to and to The Transplantation and the Global for Transplantation for and in of outcomes for kidney transplant recipients the from the following conference National Kidney Foundation of The for Transplant and and also of from the to and of the for