ABSTRACT

Over the past 50 years the short-term improvement in one year graft survival in solid organ transplantation has improved dramatically. The latest statistics from the Scientific Registry of Transplant Recipients (SRTR) for 2006 demonstrate graft survivals in kidney, liver, lung and heart transplant patients at the first year that approach or exceed 9096.1 These advances have occurred despite the fact that recipients are older with more comorbid illnesses and cadaver donors are less ideal.2*4 Progress in surgical techniques and preservation has contributed to this progress in one year graft survival, particularly for liver and lung transplantation.5 7 The biggest improvement has been in our understanding of immunosuppression.810 Pretransplant work-ups allow the identification of specific alloantibody to be avoided in the donor.11'14 Flow crossmatches at the time of transplant allow faster and more sensitive detection of antibody that may be missed by conventional techniques.1517 After transplantation, there are a greater variety of potent pharmacological agents to choose from and there is a better rationale of how to administer them. Drug regimens can be individualized for groups, such as African Americans or diabetics, but also for specific patients.18 21 Monitoring is no longer limited to measur­ ing trough levels at every clinic visit. Immune cell function and short term area under the curve (AUC) calculations have become common­ place.22'27 If a patient has an adverse reaction to a particular class of drugs, that drug class can be minimized or eliminated after transplantation with equivalent immunologic results. Long-term single antigen assays can now detect the new onset of antibody against donor.28,29 When it is detected and confirmed by biopsy there are techniques to mitigate their presence and improve allograft function.3^ 32

The majority of renal recipients are at highest risk of death from coronary vascular disease, much like the general population.33,34 While that observation is laudable chronic graft failure continues to complicate long-term morbidity and survival in all solid organs. This book attempts to identify the factors that contribute to this failure of long-term function.