Long-term posttransplantation care: the expanding role of community nephrologists

Improvements in transplantation practices, immunosuppressive agents, and management of comorbid conditions have led to better outcomes for kidney transplant recipients. Transplantation has become the treatment of choice for patients with end-stage renal disease (ESRD). This has resulted in continued growth in the number of patients living with a functioning kidney allograft as a percentage of the total ESRD population. These patients require long-term follow-up care, which already is straining the limited resources of transplant centers. Community nephrologists are the logical choice to assume responsibility for the posttransplantation care of these patients after discharge from transplant centers when they are stabilized. Optimal management of kidney transplant recipients depends on regular interactive communication between the patient's community nephrologist and the transplant center. Open communication will not only facilitate the initial transition of care, it also will decrease the frequency of referrals back to the transplant center. In an ideal situation, the transplant center and community nephrologist would develop and discuss plans for discharge and transition of care for the individual patient before the actual kidney transplantation. Important issues for effective communication include changes in laboratory results and kidney function; pretransplantation and posttransplantation comorbid conditions, surgical complications, or adverse effects of medications; modifications to immunosuppressive therapy or other medications; recurrent hospitalizations or emergency care; and changes in biopsy results.