Long-term renal transplantation. Recent successes and new problems

Area of Science:

• Nephrology
• Immunology
• Transplantation

Background:

• Significant advancements in preventing early acute kidney transplant rejection and increasing one-year allograft survival rates have been observed.
• However, challenges persist, including unrecognized subclinical rejections, the rise of acute and chronic humoral rejection, and the potential inadequacy of current strategies for long-term graft survival without adjunctive therapies.

Purpose of the Study:

• To review current trends in kidney transplantation, focusing on improvements, persistent concerns, and future directions.
• To analyze factors contributing to long-term renal allograft success, particularly in recipients with a history of acute rejection.
• To explore potential adjunctive therapies for long-term graft and recipient health.

Main Methods:

• Review of recent studies and clinical observations in renal transplantation.
• Analysis of outcomes in long-term renal transplant survivors, including immunological profiles.
• Discussion of the role of cyclosporine (CSA) and emerging therapeutic strategies.

Main Results:

• Cyclosporine (CSA) use has evolved with lower dosing, conversion protocols, and broader applications.
• Long-term transplant survivors often exhibit B cell depletion, potentially protecting against late humoral rejection, despite experiencing early acute rejections.
• Chronic allograft nephropathy (CAN) remains a significant challenge, though hypomagnesemia is an area of recent investigation.

Conclusions:

• Future kidney transplantation therapies will likely incorporate adjunctive agents with anti-proliferative and anti-fibrogenic properties.
• Targeting excessive proliferative activity, common in chronic allograft injury and transplant complications like cardiovascular disease and skin cancer, is crucial.
• Long-term management strategies aim to protect both the allograft and the recipient using agents such as renin-angiotensin-aldosterone system inhibitors, statins, sirolimus, mycophenolic acid, and leflunomide.