Immunosuppression and Results in Renal Transplantation

Keeping a balance between the effective prevention of rejection and the side effects of immunosuppressants is a key point for long-term renal transplantation success. Today antibody induction (either basiliximab or depleting polyclonal antibodies for high-risk patients) together with an initial combination therapy of calcineurin inhibitor (CNI), mycophenolate, and steroids is recommended and results in excellent early outcomes. Yet despite the significant decrease in the incidence of acute rejection, long-term graft loss has remained rather constant over the last 25 yr. Thus new immunosuppressive combination strategies, avoiding or minimising CNIs, have been a goal in many randomised controlled trials during the last decade. Although it is too early to reach conclusions about the success of these strategies, some results are rather encouraging, in particular strategies including novel biotherapies like belatacept. This review updates the current knowledge and indications of modern immunosuppressants in the setting of renal transplantation and offers an overview of the regimen strategies available to minimise long-term side effects and prolong the survival of both patients and allografts.Patient summary Modern immunosuppression strategies with calcineurin inhibitors (CNIs) and mycophenolate have reduced incidence of acute rejection but failed to improve long-term renal outcome. Efforts to minimise or replace CNIs have led to encouraging results, but long-term follow-up and integration of new drugs in these strategies are required to really improve long-term results after renal transplantation.