Abstract
Environmental exposure to heavy metals, such as cadmium, lead, arsenic, and copper, represents a significant yet underappreciated threat to the long-term survival of kidney transplants. Accumulating epidemiological evidence consistently links even low-level exposure to a substantially elevated risk of late graft failure. The transplanted kidney is particularly vulnerable due to its heightened susceptibility to oxidative stress, compounded by immunosuppressive therapy and often impaired excretory function. The core pathophysiological mechanism involves the accumulation of heavy metals in the renal cortex, where they disrupt mitochondrial function and catalyze the generation of reactive oxygen species (ROS) via Fenton-like reactions. This oxidative surge depletes antioxidant defenses, triggering a deleterious cascade of inflammation, apoptosis, and fibrosis, which accelerates the progression of chronic allograft injury. Recognizing this modifiable environmental risk factor is paramount for improving outcomes. This review synthesizes the current evidence and proposes a multi-pronged management strategy, encompassing rigorous biomonitoring, targeted dietary interventions, and novel therapeutic approaches, such as mitochondrial transplantation and the use of natural antioxidants, to mitigate heavy metal toxicity and enhance graft longevity.