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Drug Insight: maintenance immunosuppression in kidney transplant recipients

Nature Clinical Practice Nephrology volume 2, pages 688–699 (2006)Cite this article

Abstract

Kidney transplantation is the treatment of choice for patients with end-stage renal disease, in part because of ongoing efforts towards improving immunosuppressive strategies. Although calcineurin inhibitors remain the mainstay of immunosuppression in kidney transplant recipients, within this class of drug there has been a shift from use of ciclosporin to use of tacrolimus. Mycophenolate mofetil and mycophenolate sodium are now the antimetabolites of choice. A new class of drugs (inhibitors of mammalian target of rapamycin) that includes sirolimus is being increasingly used in stable kidney transplant recipients. New data, however, indicate that a more cautious approach to the use of this drug is warranted. Many transplant centers are now using steroid avoidance, minimization and withdrawal protocols. The impact of these different drugs and therapeutic strategies on outcomes has to be weighed against their immunosuppressive benefit. As more and more community-based nephrologists and primary care physicians are becoming involved in the care of stable kidney transplant recipients, it is important for these clinicians to familiarize themselves with novel immunosuppressive drugs and their pharmacokinetic properties.

Key Points

  • It is increasingly common for community-based nephrologists and primary care physicians to be involved in the care of stable kidney allograft recipients during the maintenance phase of immunosuppressive therapy

  • It is important that community-based nephrologists and primary care physicians are familiar with immunosuppressive drugs that have been introduced in recent years

  • Common immunosuppressants are the calcineurin inhibitors ciclosporin and tacrolimus, the antimetabolites mycophenolate mofetil, mycophenolate sodium and azathioprine, and inhibitors of the mammalian target of rapamycin such as sirolimus

  • Protocols for avoidance, minimization and withdrawal of corticosteroids from immunosuppressive regimens are being used with increasing frequency

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Figure 1: Photographs of common immunosuppressant drugs from PDR online (http://www.pdr.net).
Figure 2: Mechanisms of action of maintenance immunosuppressive agents.
Figure 3: Trends in maintenance immunosuppression drugs used between discharge and 1 year after transplantation (1994–2003).

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Acknowledgements

Some of the work presented here was supported by grants AHA SDG 0235290N (MS), NIH KO8-DK067981 (AD); RO1-AI49285 (BNB) and K24-DK616962 (BNB).

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Authors and Affiliations

  1. Nephrology Section,

    Millie Samaniego, Bryan N Becker & Arjang Djamali

  2. Head of the Nephrology Section,

    Millie Samaniego, Bryan N Becker & Arjang Djamali

  3. Nephrology Section and the Director of Nephrology Research, all at the University of Wisconsin-Madison, WI, USA

    Millie Samaniego, Bryan N Becker & Arjang Djamali

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  1. Millie Samaniego
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Correspondence to Arjang Djamali.

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Samaniego, M., Becker, B. & Djamali, A. Drug Insight: maintenance immunosuppression in kidney transplant recipients. Nat Rev Nephrol 2, 688–699 (2006). https://doi.org/10.1038/ncpneph0343

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