Kidney transplantation: walking the thin line between benefits and harms
13 June 2017
UAntwerp, Campus Drie Eiken, Building O, theatre O5 - Universiteitsplein 1 - 2610 WILRIJK (route: UAntwerpen, Campus Drie Eiken
Prof J-L. Bosmans & Prof D. Abramowicz
PhD defence Rachel Hellemans - Faculty of Medicine and Health Sciences
Kidney transplantation is the preferred treatment for most patients with end-stage renal disease. Important medical breakthroughs such as tissue typing and potent immunosuppressive drugs allowed for a significant reduction in acute rejection rates and a strong increase in the number of kidney transplantations from the 1980s onwards. In the nineties, it was first clearly demonstrated that kidney transplantation improves patient survival compared to remaining on dialysis. Transplant care kept improving, more potent immunosuppressive regimens were developed, leading to even lower acute rejection rates and better short-term graft survival. Encouraged by these successes, we are currently exploring the limits by performing transplantation in various high-risk settings.
Still, the classical post-transplant complications remain very challenging and although many therapeutic options are currently available, we need to carefully balance their potential benefits versus harms. We have, for example, an arsenal of very potent immunosuppressive drugs, but these may be associated with a higher risk of infection and malignancy. We can perform transplantation in HLA-immunized patients or do HLA-incompatible transplantation, but it implies a higher risk of rejection. We can transplant elderly or otherwise fragile patients but at the cost of an increased risk of post-operative complications. In addition, as more patients are considered to be transplant candidates, we are increasingly facing organ shortage. As a result, kidneys that previously would not have been considered for transplantation because of inferior quality are now frequently used, such as organs from older donors, and thereby we accept possible suboptimal outcomes as their use may still outweigh the risks of a prolonged waiting time on dialysis.
With these major and rapid evolutions in contemporary kidney transplantation, constant reassessment of the evidence is needed to guide physicians in choosing the best options for their patients. However, many areas of uncertainty still exist, and guidelines sometimes lag behind. In this thesis, we explore several of the most prominent gaps in knowledge concerning kidney transplantation and try to find some answers to support decision-making in everyday transplant care.
The following topics will be covered:
- Balancing costs and benefits of cytomegalovirus treatment after kidney transplantation
- Management of high-immunological risk transplantation
- Balancing risks and benefits of induction immunosuppression
- Balancing risks and benefits of kidney transplantation in the elderly