Factors associated with long-term renal allograft survival

Major advances in immunosuppression and reductions in the rates of acute rejection have led to increasing graft and patient survival rates during the past two decades. Chronic dysfunction of the renal allograft, however, remains a major clinical problem and probably represents the end result of the complex interplay between donor and recipient factors, immunologic injury, nonimmunologic insults, and drug-induced nephrotoxicity. Optimal function of the renal allograft is obtained by maintaining a balance between underimmunosuppression and acute rejection and overimmunosuppression and drug-induced toxicities. To minimize side effects while maintaining efficacy, immunosuppressive drugs are commonly used as combination therapy. Pharmacokinetic and pharmacodynamic interactions between these agents can affect graft survival and function. The evidence supporting the role of therapeutic drug monitoring as applied to commonly used immunosuppressants in modern transplantation is presented here, and the increasing role of therapeutic drug monitoring in the optimization of graft and patient survival rates in the modern era of renal transplantation is discussed.