Transplant Onconephrology: An Update

Abstract

Transplant onconephrology is a growing specialty focused on the health care of kidney transplant recipients with cancer. Given the complexities associated with the care of transplant patients, along with the advent of novel cancer therapies such as immune checkpoint inhibitors and chimeric antigen-receptor T cells, there is a dire need for the subspecialty of transplant onconephrology. The management of cancer in the setting of kidney transplantation is best accomplished by a multidisciplinary team, including transplant nephrologists, oncologists, and patients. This review addresses the current state and future opportunities for transplant onconephrology, including the roles of the multidisciplinary team, and related scientific and clinical knowledge.

Keywords: Transplant onconephrology; cancer; chimeric antigen–receptor T cell; immune checkpoint inhibitor; immunosuppression; immunotherapy; kidney transplant.

Figure 1.

Cancer immunotherapy. Immunotherapy targets immu necheck point proteins (eg, PD-1, PD-L1,CTLA-4) to prohibit T-cell anergy orapoptosis and tumor-specific antigens with engineered T cells (CART-cells). Abbreviations: Ab, antibody; CD28, cluster of differentiation 28; CTLA-4, cytotoxic T-lymphocyte–associated antigen-4 protein; IL-2, interleukin2; MHC1, major histocompatibility class 1; PD1, programmed death-1 protein; PDL1, programmed deathligand 1 protein; TCR, T-cell receptor. Reprinted with permission of Christopher D. Blosser and artist Danielle Eble (https://www.danielleeble.com).

Figure 2.

Transplant immunosuppression. Immunosuppression targets intracellular (eg, calcineurin inhibitors such as tacrolimus and cyclosporine) and extracellular molecules (eg, belatacept, basiliximab)to prohibit immune cell activation and proliferation. Abbreviations: CTLA-4, cytotoxic T-lymphocyte–associated antigen-4 protein; IL-2, interleukin 2; mRNA, messengerRNA; TCR, T-cell receptor. Reprinted with permission of Christopher D. Blosser and artist Danielle Eble (https://www.danielleeble.com).

Figure 3.

General principles of immunosuppression management in kidney transplant recipients with cancer. Abbreviations: MMF, mycophenolate mofetil; MPA, mycophenolic acid; mTOR, mammalian target of rapamycin; NSAID, nonsteroidal anti-inflammatory drug; PPI, proton pump inhibitor; SCC, squamous cell carcinoma.