Therapeutic strategies in immunosuppression after renal transplantation

Immunosuppressive strategies are directed at both the prevention and treatment of rejection. Strategies to prevent rejection are based on cyclosporine, and aim to achieve improved graft survival while decreasing the incidence of nephrotoxicity, and include the use of low doses of cyclosporine, cyclosporine conversion protocols, triple therapy (with low doses of azathioprine, cyclosporine, and steroids), and delayed administration of cyclosporine. There is no agreement as to the most satisfactory protocol at this time, but the use of cyclosporine has allowed the use of low doses of steroids or even discontinuation of steroid therapy, a major advance in pediatric transplantation. The treatment of rejection still depends on the use of high doses of steroids, but heterologous anti-lymphocyte globulin and OKT3, a pan-T monoclonal antibody, can be used with success in steroid-resistant rejection episodes. Other monoclonal antibodies directed at leukocyte subpopulations are likely to be of value in time as our understanding of the mechanisms of rejection of renal allograft increases.