Calcineurin inhibitors in kidney transplantation: friend or foe?

Abstract

Purpose of review: The utilization of calcineurin inhibitors (CNI) in kidney transplantation has dramatically improved short-term outcomes but significant gains in long-term outcomes have proved elusive. Nephrotoxicity is the major problem associated with CNIs and is responsible for the disappointing progress seen in long-term graft survival. In this review, we assess CNI efficacy as well as the latest strategies employed to limit long-term CNI nephrotoxicity.

Recent findings: Three CNI sparing strategies - CNI withdrawal, CNI avoidance, and CNI minimization - are evaluated with discussion of key studies such as the Efficacy Limiting Toxicity Elimination-Symphony and Spare-the-Nephron studies. Recent breakthroughs in transplant immunosuppression are discussed such as the BENEFIT and BENEFIT-EXT studies, which have led to the recent US Food and Drug Administratrion approval of belatacept, a novel T-cell costimulation blocker.

Summary: For now, CNIs remain the proven standard of care in modern immunosuppression. However, some novel agents may challenge the role CNIs play in kidney transplantation in the very near future.