Progression factors in chronic kidney disease. Non-immunological mechanisms

Non-immunological factors in the progression of kidney disease in transplant patients are the following: high blood pressure, proteinuria, dislypidemia, etc. 1. Arterial hypertension treatment: Blood pressure must be measured periodically in all transplant patients. Similarly to native kidneys, in renal transplant patients arterial hypertension is a risk factor in the progression of kidney disease. Arterial hypertension represent a clinical marker of chronic allograft nephropathy and contributes to graft loss and to the morbid- mortality of these patients (Evidence level C). Blood pressure control should be < 130/80 mm Hg for renal transplant patients without proteinuria and 125/75 mm Hg for proteinuric patients (> 1 g/24 hours). Hypertension and proteinuria are frequently associated in the same patients, a global treatment of both seems more rational (Evidence level C). General measures should be instigated first with pharmacological therapy. All antihypertensive drugs are useful in renal transplant patients and the majority of patients will need two or more drugs. In proteinuric patients an angiotensin receptor antagonist or an ACE-inhibitor should be initiated. It is advisable to monitor the serum potassium and creatinine after the start of this drugs or during the treatment periodically, especially in patients with chronic kidney disease stage IV-V. 2. Proteinuria treatment: Proteinuria has been strongly correlated with reduced function and graft survival. Lowering proteinuria to values as near to normal as possible (< 0.5 g/24 hours). To reduce proteinuria, an angiotensin receptor antagonist, an ACE-inhibitor or a combination of both are required, with serum potassium or creatinine monitoring, especially in patients with chronic kidney disease stage IV-V. 3. Dyslipidemia treatment: For kidney transplant recipients the assessment of dyslipidemias should include a complete fasting lipid profile with total cholesterol, LDL, HDL, and triglycerides. Evidence from the general population indicates that treatment of dyslipidemias reduces cardiovascular disease and evidence in kidney transplant patients suggests that judicious treatment can be safe and effective in improving dyslipidemia. Therapeutic goal must be LDL < 100 mg/dl. (Evidence level C). 4. Others: Cigarette smoking, glucose intolerance or diabetes control and obesity should be assessed.