Renal protective strategies in heart transplant patients.
OBJECTIVE
Chronic renal failure associated with long-term calcineurin inhibitor immunosuppression is a substantial clinical problem in the heart transplant population, compounded by difficulties in identifying patients likely to develop renal dysfunction. Several approaches, however, have been developed or are being investigated to preserve renal function in heart transplant patients.


RESULTS
Approaches to identify patients with an increased risk of developing renal dysfunction are being refined, and improved calcineurin inhibitor monitoring strategies are being investigated. Novel immunosuppressive regimens including mycophenolate mofetil and/or rapamycin that lack nephrotoxicity promise new therapeutic strategies with the efficacy of calcineurin inhibitor-based combinations. Temporary ('holiday') or permanent ('retirement') calcineurin inhibitor replacement with interleukin-2 receptor monoclonal antibodies has the potential to halt progressive renal dysfunction. Finally, emerging data on the renal protection afforded by angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, either singly or in combination, provide another avenue of investigation.


CONCLUSIONS
Several strategies have demonstrated their potential to preserve or improve renal function in heart transplant patients in small studies. Large randomized controlled trials are necessary to determine the optimal strategies to prevent rejection while preserving renal function in the long-term management of heart transplant patients.
Cantarovich
Marcelo
M
Multiorgan Transplant Program, Department of Medicine, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada. marcelo.cantarovich@muhc.mcgill.ca
D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D019703:Calcineurin / Q000097:blood; D065095:Calcineurin Inhibitors; D016027:Heart Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000097:blood; D007668:Kidney / Q000187:drug effects / Q000378:metabolism / Q000503:physiopathology; D007676:Kidney Failure, Chronic / Q000139:chemically induced / Q000503:physiopathology / Q000517:prevention & control*
D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D065095:Calcineurin Inhibitors; D007166:Immunosuppressive Agents; D019703:Calcineurin