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Kidney transplant from a living donor is known to be the best renal replacement therapy. While not as common as in northern Europe and the USA, living donor transplants are on the rise in Italy. Although there is a large body of evidence in the literature about the safety of the surgical procedure, the risk of long-term complications for the donor has not been clearly defined because of the lack of studies with adequate follow-up and a sufficient number of subjects involved. The main questions concern the development of chronic kidney disease in the donor, expressed as a GFR decline or the presence of microalbuminuria. The physiopathological basis of GFR decline and proteinuria development may differ from the model of nephropathy in patients with two kidneys, and this could involve prognostic differences too, particularly with regard to the cardiovascular risk. Detailed and prolonged follow-up programs are needed to monitor and, if necessary, treat long-term complications in kidney donors.

We report a case of Kaposi's sarcoma in a patient who received a double kidney transplant in 2005. Immunosuppression was induced with rapamycin and antilymphocyte serum while maintenance therapy consisted of rapamycin, corticosteroids and mycophenolic acid. The patient developed delayed graft function but no rejection. In November 2006 and March 2007 two graft biopsies were taken because of a significant rise in serum creatinine; they revealed chronic allograft nephropathy and polyomavirus infection. Meanwhile a skin biopsy of the leg was performed to determine the nature of a discolored lesion. The morphohistological diagnosis was Kaposi's sarcoma. For this reason rapamycin was stopped and steroid treatment gradually reduced. Specific therapy with doxorubicin was started; radiological and endoscopic examination excluded disseminated disease while serological tests were positive for antibodies to HHV-8, a virus known to cause Kaposi's sarcoma. Unfortunately, withdrawal of antirejection therapy caused loss of the graft, so the patient had to start dialysis. In this report we stress the possible development of malignancy in transplanted patients who are given rapamycin. Rapamycin is known to be an antirejection drug and to have antineoplastic activity; the major risk of malignancy is probably related to immunosuppression rather than the type of drugs used to obtain it.