Clinical immunosuppression – current status

The current immunosuppressive regimens allow to achieve the excellent one year organ survival, exceeding in renal transplantation 90%, with acute rejection rate below 15%. However, this medal has the reverse side, and it is price to pay. 54% of the kidney allograft is lost due to the recipient death with the functioning graft, mainly due to cardiovascular diseases, infection and malignancy. 40% of the graft failure is caused by chronic allograft injury (CAI) which encompasses calcineurin inhibitor nephrotoxicity, chronic rejection, and toxicity occurring simultaneously with inadequate, not controlling alloresponse immunosuppression. The present strategies of initial post transplantation immunosuppressive treatment are diversified based on the evaluation of the recipient immunologic risk and of the delayed graft function occurrence threat. For low immunologic risk recipients, calcineurin inhibitor containing regimen; with or without anti CD25 antibody are recommended. High immunologic risk recipients are treated by polyclonal anti T-cell antibodies, with subsequent calcineurin inhibitor introduction. The polyclonal anti T-cell antibodies are also administrated in the delayed graft function appearance or when expectation for it's appearance is high. The main long-term goal in the post transplantation immunosuppressive treatment is to achieve the balance between efficacy and toxicity of the immunosuppressive regimen, with the reduction of the overall side effect "load" on patients. For that purpose two general approach are applied: corticosteroid withdrawal and avoidance protocols, and calcineurin inhibitor withdrawal/minimization protocols.

Keywords: Transplantation, Cardiovascular Diseases, nephrotoxicity