Minimization of immunosuppression in kidney transplantation.
OBJECTIVE
In an effort to reduce the long-term toxicities of immunosuppressant drugs, corticosteroid and calcineurin inhibitor-sparing immunosuppression protocols have become increasingly popular in managing kidney transplant recipients. This article focuses on outcomes of these strategies described in recently published trials.


RESULTS
The use of induction antibody therapy and potent residual immunosuppressants has increased the safety of steroid-free regimens, resulting in a paradigm shift towards earlier elimination of steroids after kidney transplantation. Even in the modern era, results of randomized trials generally indicate that steroid elimination increases the risk of rejection compared with maintenance steroid therapy. Among calcineurin inhibitor-sparing strategies, withdrawal of these agents after their initial use in stable patients, or conversion to either mycophenolate mofetil or sirolimus in patients with early renal dysfunction appears to yield the greatest benefit in preserving renal function. The outcomes of calcineurin inhibitor avoidance protocols have been mixed and have fallen into disfavor.


CONCLUSIONS
The benefits of minimizing immunosuppression in kidney transplant recipients must be weighed against the risks of precipitating acute rejection or chronic allograft dysfunction. Additional research is needed to identify clinical and immune parameters that will enable selection of patients for whom the benefits outweigh the risks.
Augustine
Joshua J
JJ
Department of Medicine, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, Ohio 44106, USA.
Hricik
Donald E
DE
D048868:Adaptor Proteins, Signal Transducing; D000305:Adrenal Cortex Hormones; D019703:Calcineurin; D000075202:Contraindications; D006801:Humans; D007165:Immunosuppression Therapy / Q000009:adverse effects*; D016030:Kidney Transplantation / Q000379:methods* / Q000451:nursing*; D018570:Risk Assessment; D016896:Treatment Outcome
D048868:Adaptor Proteins, Signal Transducing; D000305:Adrenal Cortex Hormones; C491861:CABIN1 protein, human; D019703:Calcineurin