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A Journal on Nephrology and Urology

Indexed/Abstracted in: EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
Impact Factor 0,536

Frequency: Bi-Monthly

ISSN 0393-2249

Online ISSN 1827-1758


Minerva Urologica e Nefrologica 2003 March;55(1):13-24


Long-term renal transplantation. Recent successes and new problems

Braun W. E.

Depart­ment of Neph­rol­o­gy and Hyper­ten­sion, Cleve­land Clin­ic Foun­da­tion, Cleveland, OH, USA

There has ­been con­tin­ued improve­ment in pre­vent­ing ear­ly biop­sy-­proved ­acute rejec­tions and increas­ing 1-­year allo­graft suc­cess ­rates, and, ­after ­some ­delay, the con­di­tion­al ­half-­life of ­grafts. ­Beneath ­these impres­sive achieve­ments are sev­er­al trou­bling con­cerns: unrec­og­nized sub­clin­i­cal rejec­tions; the emer­gence of ­acute and chron­ic humo­ral rejec­tion; the dif­fer­ent ­effect of cer­tain ­acute rejec­tions on the devel­op­ment of chron­ic rejec­tion; the pos­sibil­ity ­that the cur­rent improve­ments in reduc­ing ear­ly ­acute rejec­tion may not be trans­lat­ed ­into long­er ­half-­life for the ­graft ­unless impor­tant adjunc­tive ther­a­py is includ­ed. The use of cyclo­spo­rine (CSA) has ­been ­reshaped by low­er dos­ing, con­ver­sion and avoid­ance pro­to­cols, C2 ­blood lev­el mon­i­tor­ing, avail­abil­ity of gener­ics, and appli­ca­tion to non-trans­plant immu­no­log­i­cal­ly-medi­at­ed ­renal dis­eas­es. The enig­ma of chron­ic allo­graft neph­rop­a­thy (CAN) unfor­tu­nate­ly ­still ­remains, but ­recent stud­ies on the ­effects of hypo­mag­ne­se­mia are pro­voc­a­tive. The actu­al ­cohort of tru­ly ­long-­term ­renal trans­plant suc­cess­es is pro­vid­ing remark­able ­insights ­into the way ­such ­grafts and ­their recip­ients ­achieve 30-­year suc­cess. ­More ­than ­half of ­these ­patients ­have expe­ri­enced ear­ly ­acute rejec­tions (­even ­Banff II and III). Some­what con­trary to expec­ta­tions, ­these recip­ients usu­al­ly do not ­have sub­nor­mal lev­els of CD4+ and CD8+ lym­pho­cytes. How­ev­er, ­they are typ­i­cal­ly B ­cell deplet­ed, a con­di­tion ­that may pro­tect ­them ­from ­late humo­ral rejec­tion. ­Future direc­tions ­will like­ly ­lead to the inclu­sion of impor­tant adjunc­tive ­agents hav­ing sec­on­dary ­anti-pro­life­ra­tive and ­anti-fibro­gen­ic capa­bil­ities. ­Because chron­ic inju­ry to ­renal allo­grafts, as ­well as the dom­i­nant com­pli­ca­tions of ­renal trans­plan­ta­tion ­such as car­di­o­vas­cu­lar dis­ease and ­skin can­cers, are wov­en togeth­er by a com­mon ­theme of exces­sive pro­life­ra­tive activ­ity, ­albeit of dif­fer­ent ­cell ­types, ­long-­term ther­a­py ­will be direct­ed at ­both pro­tect­ing the allo­graft and the allo­graft recip­i­ent by incor­po­rat­ing as ­long-­term ther­a­py select­ed ­anti-pro­life­ra­tive ­agents ­that ­could ­include inhib­i­tors of the ­renin-angio­ten­sin-aldos­te­rone ­system, sta­tins, sirol­i­mus, mycoph­e­nol­ic ­acid and leflu­no­mide.

language: English


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