Renal-sparing strategies in cardiac transplantation

TY - JOUR

T1 - Renal-sparing strategies in cardiac transplantation

AU - Gustafsson, Finn

AU - Ross, Heather J

N1 - Keywords: Glomerular Filtration Rate; Graft Rejection; Heart Failure; Heart Transplantation; Humans; Immunosuppressive Agents; Kidney; Prognosis; Renal Insufficiency; Risk Factors

PY - 2009

Y1 - 2009

N2 - PURPOSE OF REVIEW: 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. RECENT FINDINGS: 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. SUMMARY: 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.

AB - PURPOSE OF REVIEW: 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. RECENT FINDINGS: 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. SUMMARY: 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.

U2 - 10.1097/MOT.0b013e32832e6f7b

DO - 10.1097/MOT.0b013e32832e6f7b

M3 - Journal article

C2 - 19542890

SN - 1087-2418

VL - 14

SP - 566

EP - 570

JO - Current Opinion in Organ Transplantation

JF - Current Opinion in Organ Transplantation

IS - 5

ER -