Progress in renal transplantation

The improvements in renal transplantation over the last 10 years have been one of the great success stories in medicine. We reviewed these successes with a focus on the following: changes in demographics of donors and recipients in Canada, the benefits of new immunosuppressive regimes and the efforts to minimize their toxicity and finally, our understanding of measures to circumvent chronic rejection.

A review of current transplantation literature was performed and pertinent data presented. As well, information from the Canadian Organ Replacement Register was selected to provide an overview of changes in renal transplantation in Canada.

Despite the stable rate of transplantation in Canada, the number of new patients starting dialysis each year roughly equals the entire national renal transplant waiting list. These patients are older and have more complex co-morbidities mandating prudent use of immunosuppression so as to minimize toxicity. Standard triple therapy consists of a calcineurin inhibitor, an antimetabolite and corticosteroids. Antibody therapy is indicated in sensitized recipients and newer monoclonal humanized antibodies offer less toxicity. Nonspecific therapies are less favorable due to unwanted side effects and we can now identify subsets of patients who are most likely to benefit from specific therapy. Newer non-nephrotoxic agents hold promise for future regimens. However a paucity of large, multicenter, randomized trials, tested against standard protocols, limits their current indications. Many immunologic and non-immunologic factors influence the outcome of renal transplantation and play a role in the development in acute and chronic rejection.

The challenges of renal transplantation over the next 10 years are: 1) in the development of specific therapies that can be altered according to patient co-morbidities and other factors influencing outcome; 2) minimizing toxicity; 3) preventing chronic rejection; and 4) improving our national organ donation network.