Immunosuppression is an obligate necessity in kidney transplant. However, the standard immunosuppression causes chronic deterioration of allograft function over long term use. Mammalian target of rapamycin (mTOR) inhibitors provide an alternative in such scenario. The mTOR inhibitors engage FKBP12 to create complexes that engage and inhibit the target of rapamycin. Inhibition of the TOR blocks signal 3 by preventing cytokine receptors from activating the cell cycle. mTOR inhibitors are associated with less viral infection and disease in kidney transplants and also beneficial in post-transplant malignancy. There are various strategies of using mTOR inhibitors either as upfront de novo therapy or later on as switch over therapy. They can also be used in cases of complications arising from standard immunosuppression. mTOR inhibitors also have adverse effects which can be managed by dose reduction but may require stoppage in case of serious complications. Surgical issues need to be kept in mind in view of delayed wound healing. mTOR inhibitors add on to the armamentarium of the available immunosuppression and can give excellent results with judicious use. The present review aims to provide updated information regarding the use of these drugs in post-renal transplantation setting.

Renal vein thrombosis (RVT), though very rare, is one of the serious and fatal vascular complications of renal transplantation, which may lead to graft loss. The causative factor may be unknown in majority of cases. However, a variety of causes have been identified. Here, we report a case of a 46-year-old postrenal transplant male patient, who presented with acute onset of right flank pain, tenderness, hematuria, and reduced urine output after 40 months of transplantation. Renal vein thrombosis distal to the level of hilum of transplanted renal vein was found on color Doppler study. The patient was treated with standard anticoagulant drug therapy and eventually he had to undergo graft nephrectomy. Unfortunately, on second postoperative day, the patient expired due to cardiac arrest. Radiology, in particular color Doppler study, plays an important role as a noninvasive investigation to diagnose RVT at the earliest and to guide prompt management.

Malignancies in renal transplant recipients (RTRs) usually have an aggressive biological behavior. They are detected at an advanced stage and have a poor survival rate. Post-transplant urinary bladder malignancy is an uncommon occurrence and most of these patients are in their 5th or 6th decade. We report a rare occurrence of bladder cancer in RTR in the 4th decade more than 10 years after renal transplantation with rapid progression and death within 12 weeks of diagnosis.

Empyema necessitans is a rare sequel of untreated pleural space infection and is most commonly secondary to tuberculosis. Isolated tuberculous empyema necessitans in a renal transplant recipient is extremely rare. It is an important differential diagnosis of a chest mass in renal transplant recipient. Early identification and treatment prevents progression and morbidity. We hereby report a 62-year-old male renal transplant recipient who presented with classical features of tubercular empyema necessitans and was managed with antitubercular therapy and tube thoracostomy drainage.

Urolithiasis is one of the most common conditions seen in urology practice. Renal transplantation is associated with a lower incidence of urolithiasis compared to general population. In these patients, the incidence of isolated ureteric calculi is 5–10 times lower than renal calculi. If renal and/or ureteric calculi are present in transplanted kidney, they must be attended urgently as the presentation in such patients is atypical due to lack of sympathetic innervation of the graft kidney and the condition may rapidly progress to graft dysfunction. The diagnosis of renal and upper ureteric calculi is usually made on graft ultrasonography. For mid and distal ureteric calculi, CT and MR urography are more sensitive. For nonobstructive calculi, treatment is with extracorporeal shock wave lithotripsy (ESWL) or flexible ureteroscopic removal for smaller stone burden (<1.5 cm) while obstructive calculi and larger stones are best addressed with percutaneous nephrostomy followed by percutaneous nephrolithotomy (PCNL) or ESWL or endoscopic removal.

Early post-kidney transplant period is at high risk of acquiring fungal infections due to maximum immunosuppression. We are reporting case of a 39-year-old male who did well for 16 years after renal transplantation, and then had gastric mucormycosis mimicking acute pancreatitis while on low dose maintenance immunosuppression. At admission, his clinical and laboratory parameters were suggestive of the acute pancreatitis but further worsening needed invasive investigations. Endoscopy was done and histopathology of large irregular gastric ulcer with yellow base and raised margin and tissue staining confirmed the fungus. Subsequent treatment with combined fungal therapy of amphotericin and posaconazole did not save our patient. The case highlights that mucor can present late when on low dose immunosuppression and can mimic acute pancreatitis.