Kidney transplantation (KTx) is the best option of renal replacement therapy (RRT) in terms of the prognosis of patients with end stage kidney disease (ESKD). The success in KTx requires the multidisciplinary medical approaches, such as management of complications with ESKD, infection control, and cardiovascular management, and it has been emphasized recently in Japan that nephrologists should be as much involved in KTx as in hemodialysis and peritoneal dialysis. Kidney Disease Improving Global Outcomes (KDIGO) and Japanese Society for Clinical Renal Transplantation established the clinical practice guidelines for KTx in 2007 and 2011, respectively, and these guidelines extensively describe post-transplant care for kidney transplant recipients. However, they do not refer to the pre-transplant management. There is some good evidence to suggest pre-transplant care may be associated with better KTx patient outcomes. The preparation for KTx should start from the time of recognition of chronic kidney disease (CKD), and should occur in parallel with efforts to prevent and delay its progression. This review focuses on pre-transplant management for KTx from the standpoint of nephrologists; ① Pre-transplant management of renal failure/dialysis ② Pre-transplant infection control (pre-transplant vaccination) ③ Pre-transplant diagnosis of native kidney disease. The pre-transplant care by nephrologists, who have seen CKD patients longer before KTx than transplant surgeons, is an important key to greater success in KTx.

Polyomavirus BK (BKV) is an important pathogen in kidney transplant patients. Currently, preemptive reduction of immunosuppression is recommended in viremic patients. But there are few studies which focus on BK viruria without development of viremia and nephropathy. We identified 385 kidney transplant patients with isolated viruria determined by quantitative polymerase chain reaction (PCR) with urine and plasma. We compared clinical features such as the incidence of rejection, frequency of rejection episodes, histological findings, response to bolus methylprednisolone, and graft survival between viruric patients and 515 patients without BKV replication. We sub-classified viruric patients in 3 subgroups; (a) viruria with low viral load (200～1,000copies/mL), (b) transient viruria (＞1,000copies/mL, single positive test), and (c) sustained viruria (＞1,000copies/mL, 2 or more consecutive positive test). Patients with sustained viruria showed more frequent episodes of rejection, and the development of viruria preceded the onset of rejection in most episodes. The rejection episodes developed during sustained viruria showed resistance to bolus methylprednisolone, and concurrent vruria is an independent risk factor of steroid resistance determined by multivariate logistic regression analysis. In summary, BK viruria might stimulate alloimmune response as well as antiviral immune response, and might cause frequent and steroid resistant episodes of rejection. However, these findings should be confirmed by multicenter, prospective studies.

Hyperuricemia is a metabolic disease that is noted frequently in renal transplant recipients, with a prevalence of 40％〜60％ reported in recent years. It is well known that hyperuricemia decreases kidney function and increases the risk of cardiovascular disease. Therefore, hyperuricemia is an clitical complication that may affect the long-term outcome of renal transplantation. Risk factors for the development of hyperuricemia include male gender, use of β-blockers, diuretics, or calcineurin inhibitors, history of hypertension, and long-term dialysis. Hyperuricemia is diagnosed when the serum uric acid level exceeds 7.0mg/dL, which may result from decrease in excretion or increase in the production of uric acid. Therefore, the underlying hyperuricemia should be treated on the basis of its cause. Also, unlike the general population, for the management of hyperuricemia in renal transplant recipients, one needs to take into account a possible decrease in renal function and also the characteristics of the drug used for the treatment. Thus, it may be possible to prevent deterioration of renal function by performing appropriate treatment, which in turn leads to an improvement in graft survival.

The number of living donor kidney transplants has been increasing since the introduction of new immunosuppressive drugs such as calcineurin inhibitors, mycophenolate mofetil and basiliximab in Japan. On the other hand, that of deceased donor transplants has remained about 200 in a year in these 30 years. In 2012, 1,610 transplants including 1,417 from living donor and 193 from deceased donor transplants were performed. The expanding indications for transplantation in various aspects, such as elderly recipients and donors, spouse donors, ABO incompatible transplants, diabetic recipients and preemptive transplants have contributed to the increasing number of living donor transplants. The patient and graft survivals are superior in living donor transplants followed by brain dead donor and non-heart beating donor transplants. An increase in the number of deceased donors is now essential in the field of transplantation in Japan.

The necessity and timing of nephrectomy are controversial when renal transplantation for patients with autosomal dominant polycystic kidney disease (ADPKD). We experienced 30 patients with ADPKD underwent renal transplantation from February 2002 to December 2011. Of the 30 patients, we divided into 10 renal transplantation with simultaneous bilateral nephrectomies, and 20 without bilateral nephrectomies. Demographic data, intraoperative data, graft survival rate, and patient survival rate were compared. There were no differences regarding demographic data. Operating time was longer (426 vs. 194.6min, p＝0.000076) and blood transfusions was larger (746 vs. 115mL, p＝0.0024) in bilateral nephrectomies group. There were no differences in graft and patient survival rates. Volumetry was retrospectively conducted using simple computed tomography scan before and after transplantation in 12 non-bilateral nephrectomies patients. Kidney volumes were reduced in all patients after renal transplantation. Because the volume of native polycystic kidneys could be reduced after renal transplantation, It seems that there is no necessity of bilateral native nephrectomies if there are neither a hemorrhage of the cyst, infection nor a possibility of the malignant tumor for patients with ADPKD.

Introduction：Recently, the proportion of kidney transplantation for elderly End Stage Renal Disease (ESRD) patients is increasing with an increase in the total number of renal transplant in Nippon. Characteristics and clinical outcomes of recipients aged sixty years and older who underwent living donor kidney transplantation were investigated in this study. Methods：The recipients who underwent living donor kidney transplantation between March 1998 and July 2012 were divided into two groups, according to age at the time of the transplantation：young group (＜60years) and elderly group (≥60years). As clinical outcomes of transplantation, kidney function at one and three years after transplantation, the rate of acute rejection and CMV infection, and patient and death censored graft survival were compared between the two groups. Results：The proportion donor was spouse was significantly higher in the elderly group than in younger group, whereas HLA mismatch number was significantly more in the elderly group. There were no significant difference in kidney function at 1 and 3 years after transplantation, the rate of acute rejection and CMV infection, and patient and death censored graft survival between the two groups. Conclusion： It was suggested that living donor kidney transplantation could be a best treatment modality for the elderly ESRD patients who wish to receive kidney transplantation；the living donor kidney transplantation for elderly patients would yield the equivalent results to young recipients.

While baseline biopsy at renal transplantation is useful and performed routinely, the difference of pathology samples before and after allograft recirculation have not been reported. We analyzed both samples (0 and 1 hour biopsy) retrospectively and the outcome of clinical course. Firstly we compared the pathological diagnosis with Banff score for each biopsies, secondly we examined whether 1 hour biopsies could predict the postoperative clinical course. Clinical record of consecutive 43 renal transplantation was reviewed from 2009 to 2012. The pathological diagnosis included 22 no major abnormalities, 15 acute tubular injury, 1 acute tubular necrosis, 3 mesangial IgA deposition and 2 diabetic change. Diagnosis of 0 hr biopsies was exactly same as that of 1 hr, and difference of Banff score in both biopsies was within 1 grade points. Although clinical acute antibody-mediated rejection was detected in 3 cases in early days after kidney transplantation, their 1 hr biopsy revealed no major abnormalities. Mild C4d deposition on peritubular capillaries of 1 hour biopsy specimen did not affect postoperative clinical course. There was no significant pathological difference between 0 hr and 1 hr biopsies. We could not clarify clinical necessity for both biopsies for each patient.

Although improvement of kidney graft survival within 5-years after transplantation has been achieved over 95％, chronic graft deterioration still remains against long-term better survival. As chronic nephrotoxicity of calcineurin inhibitors (CNIs) is one of the major causes of chronic graft injury, minimization of CNIs with administration of everolimus (EVR), an mTOR inhibitor, is expected to relieve the toxic effect on the kidney. The aim of this preliminary study was to evaluate the availability and safety of EVR for kidney transplant patients in the maintenance phase. Materials and methods : Fifty-six kidney transplant recipients recieving CNI-based immunosuppression (30 tacrolimus and 26 ciclosporin) with pathologically CNI toxicity and/or interstitial fibrosis/ tubular atrophy (IF/TA) were included. Conversion of immunosuppression was accomplished by reducing the CNIs by 40％ and beginning EVR at 1mg, while the doses of mycophenolate mofetil and steroid remained unchanged. Blood concentration of CNIs and EVR, as well as graft function were examined, and adverse effects were evaluated. Results : The blood concentration of tacrolimus was reduced from 5.3 to 3.3ng/mL (38％ reduction), while that of ciclosporin was reduced from 137 to 79ng/mL (42％). The concentration of EVR was 2.7ng/mL in tacrolimus patients and 3.9ng/mL in cyclosporine patients. Improvement of graft function at 3 months after beginning EVR administration was observed as a 13％ increase in eGFR (41 to 46mg/dL). Furthermore, 20％ of the patients showed an increase in urine protein excretion. Although 46％ of patients experienced stomatitis, most gradually recovered. Conclusion：Immunosuppression conversion by supplemental administration of EVR along with significant reduction in CNIs was found to improve graft function in maintenance phase of kidney transplant recipients.