[Progression factors in chronic kidney disease. Immunological mechanisms]

In kidney transplantation patient and graft survival are excellent in short-term and mid-term, although they remain stable in the long-term.The incidence of acute rejection has decreased to 8%-15%.Despite marked progress in understanding immunologic mechanisms involved in transplantation, new tools are required to detect early changes that could affect allograft function allowing us to anticipate histological lesions and providing a more accurate use of immunosuppressive drugs.From an immunologic point of view, efforts should be directed to avoid interstitial fibrosis and tubular atrophy (IF/TA) and to prevent antibody-mediated rejection.The most frequent cause of late graft loss is IF/TA.Improvement in kidney transplant results have been achieved with calcineurin inhibitors -CNI- (cyclosporin and tacrolimus), antiproliferative agents (mycophenolate mofetil and enteric-coated mycophenolic acid) and T-cell depleting antibodies. The combination of tacrolimus + mycophenolate mofetil + steroids has been the gold standard in kidney transplant immunosuppression. An adequate balance in order to maintain the appropriate immune response is essential to the patient to avoid infections or neoplasias as well to prevent rejection.In renal transplant recipients with chronic kidney disease stage 4T in which renal function remains stable,immuno-suppressive drugs can be continued at the usual maintenance doses. As GFR declines, CNI and antiproliferative drugs should be reduced.