The transplant is a day. The graft is the rest of your life. That second part happens here.
What we are protecting against
Your immune system will spend decades trying to reject an organ it correctly identifies as foreign. The medications that stop it also suppress your defenses against infection and cancer.
Every decision after transplant sits on that fault line. Too little immunosuppression and you reject. Too much and you get an infection, or a malignancy, or kidney damage from the drug itself. There is no setting that eliminates both risks. There is only careful, continuous adjustment.
The regimen
Most patients take three drugs.
A calcineurin inhibitor — usually tacrolimus. Highly effective and narrow-windowed. Below the target range you reject; above it, the drug damages the very kidney it is protecting.
An antimetabolite — usually mycophenolate. Suppresses lymphocyte proliferation. Causes diarrhea and marrow suppression, and it is teratogenic, which matters enormously if you may become pregnant.
A corticosteroid — usually prednisone, at a low maintenance dose. It brings weight gain, bone loss, glucose intolerance, and cataracts.
Some patients take sirolimus or belatacept instead. Each has its own profile.
Drug levels
Tacrolimus and sirolimus are monitored by trough level — blood drawn immediately before your morning dose, not after.
This sounds like a technicality. It is not. A level drawn two hours after the dose is uninterpretable and will send us in the wrong direction.
The list of drugs that interact with tacrolimus is long and includes things people take without thinking: certain antibiotics, antifungals, calcium channel blockers, and grapefruit juice. Never start any medication, prescribed or over-the-counter, without telling us first.
What we watch for
Rejection. Often silent. It shows up as a creatinine that has drifted up, which is why we check so often. Suspected rejection is confirmed by biopsy.
Infection. CMV, BK virus, pneumocystis. BK in particular can destroy a graft quietly, and we screen for it by monitoring viral load in the blood on a schedule.
Cancer. Skin cancer, at rates many times the general population. Post-transplant lymphoproliferative disorder. You need a dermatologist annually and you need to stay out of the sun.
Everything else. Hypertension, diabetes brought on by tacrolimus and steroids, bone disease, high cholesterol, and recurrence of the original disease in the new kidney.
The schedule
Weekly at first, then every two weeks, then monthly, then every three months, then twice a year — forever.
The visits never stop entirely. The most common reason a good kidney is lost, years out, is that someone stopped taking their medication or stopped coming in. Not rejection. Not infection. Attrition.