Renal transplantation update and the role of immunosuppressive drugs

Background: Chronic Kidney Disease (CKD) is characterized by a progressive course with ongoing loss of kidney function. Once the Glomerular Filtration Rate (GFR) falls below about half of normal, kidney function tends to decline even if the initial insult to the kidney has been eliminated. Maintenance dialysis for ESRD is usually started at a glomerular filtration rate of 10 ml/minute. Some have advocated the initiation of chronic dialysis even earlier. Hemodialysis is used in approximately 90% of the ESRD patients, with the remaining 10% using peritoneal dialysis. It is usually conducted in-center in a dialysis unit and far less often at home, with a thrice-weekly schedule and 3 to 5 hours each time. If fluid overload becomes a significant problem, a fourth session is sometimes added. In a small number of dialysis programs, hemodialysis is performed for 8 to 10 hours three times a week either in the daytime or at night (nocturnal hemodialysis), or even for a few hours six times a week (daily hemodialysis). Although hemodialysis is a relatively safe procedure, several complications may still arise. Some are inherent side effects of the normal extracorporeal circuit; some result from technical errors, and yet others are due to abnormal reactions of patients to the procedure. The annual mortality rate for ESRD