Renal-sparing strategies in cardiac transplantation.
OBJECTIVE
Renal dysfunction due to calcineurin inhibitor (CNI) toxicity is a major clinical problem in cardiac transplantation. The aim of the article is to review the efficacy and safety of various renal sparing strategies in cardiac transplantation.


RESULTS
Small studies have documented that late initiation of CNI is safe in patients treated with induction therapy at the time of transplantation. Use of mycophenolate is superior when compared with azathioprine to allow for CNI reduction. More substantial reduction in CNI levels is safe and effective with the introduction of sirolimus or everolimus. However, studies that use very early CNI discontinuation have found an increased risk of allograft rejection, and this strategy requires further study before it can be routinely recommended. CNI discontinuation late after cardiac transplantation seems more effective than CNI reduction in terms of preserving renal function. Patients with longstanding CNI treatment or proteinuria are less likely to respond favourably to a switch from a CNI-based regimen to a proliferation signal inhibitor-based regimen.


CONCLUSIONS
Each cardiac transplant recipient with renal dysfunction must be individually evaluated with respect to degree of renal dysfunction, proteinuria and rejection risk and a renal sparing strategy chosen accordingly.
Gustafsson
Finn
F
Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. finng@dadlnet.dk
Ross
Heather J
HJ
D005919:Glomerular Filtration Rate / Q000187:drug effects; D006084:Graft Rejection / Q000188:drug therapy; D006333:Heart Failure / Q000601:surgery*; D016027:Heart Transplantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D007668:Kidney / Q000187:drug effects / Q000503:physiopathology; D011379:Prognosis; D051437:Renal Insufficiency / Q000209:etiology* / Q000517:prevention & control; D012307:Risk Factors
D007166:Immunosuppressive Agents