Immunosuppression en transplantation rénale

Systematic Review of Calcineurin Inhibitors and Incidence of Skin Malignancies after Kidney Transplantation in Adult Patients: A Study of 309,551 Cases

The purpose of this systematic review and meta-analysis was to compare the risk of non-melanoma skin cancer (NMSC) and melanoma development in renal transplant recipients who receive calcineurin inhibitors to that of patients treated with other immunosuppressive agents, and investigate the possible association between the type of maintenance immunosuppression and the incidence of NSMC and melanoma in this group of patients. The authors searched databases such as PubMed, Scopus, and Web of Science for articles that would help establish the influence of calcineurin inhibitors on skin cancer development. The inclusion criteria for the study consisted of randomized clinical trials, cohort studies, and case-control studies that compared patients who received kidney transplants and were treated with a calcineurin inhibitor (CNI), such as cyclosporine A (CsA) or tacrolimus (Tac), to those who received alternative immunosuppressants and did not receive a CNI. Seven articles were analyzed overall. The results revealed a correlation between CNI treatment in renal transplant recipients and increased total skin cancer risk (OR 1.28; 95% CI: 0.10-16.28; p < 0.01), melanoma risk (OR 1.09; 95% CI: 0.25-4.74; p < 0.01), and NMSC risk (OR 1.16; 95% CI: 0.41-3.26; p < 0.01). In conclusion, the calcineurin inhibitors used after kidney transplantation are associated with a higher risk of skin cancer-both non-melanoma and melanoma-when compared with other immunosuppressive therapies. This finding suggests that careful monitoring for skin lesions in post-transplant patients must be conducted. However, the decision on the kind of immunotherapy used should always be considered on an individual basis for each renal transplant recipient.

Tacrolimus: 20 years of use in adult kidney transplantation. What we should know about its nephrotoxicity

Tacrolimus (or FK506), a calcineurin inhibitor (CNI) introduced in field of transplantation in the 1990s, is the cornerstone of most immunosuppressive regimens in solid organ transplantation. Its use has revolutionized the future of kidney transplantation (KT) and has been associated with better graft survival, a lower incidence of rejection, and improved drug tolerance with fewer side effects compared to cyclosporine. However, its monitoring remains complicated and underexposure increases the risk of rejection, whereas overexposure increases the risk of adverse effects, primarily nephrotoxicity, neurotoxicity, infections, malignancies, diabetes, and gastrointestinal complaints. Tacrolimus nephrotoxicity can be nonreversible and can lead to kidney graft loss, and its diagnosis is therefore best made with reference to the clinical context and after exclusion of other causes of graft dysfunction. Many factors contribute to its development including: systemic levels of tacrolimus; local renal exposure to tacrolimus; exposure to metabolites of tacrolimus; local susceptibility factors for CNI nephrotoxicity independent of systemic or local tacrolimus levels, such as the age of a kidney; local renal P-glycoprotein, local intestinal and hepatic cytochrome P450A3, and renin angiotensin system activation. The aim of this review is to describe the pharmacokinetics, pharmacodynamics, and mechanisms of acute and chronic tacrolimus nephrotoxicity in adult KT.

[Immunology and immunosuppression in kidney transplantation. ABO and HLA incompatible kidney transplantation]

OBJECTIVES

To perform a state of the art about immunological features in renal transplantation, immunosuppressive drugs and their mechanisms of action and immunologically high risk transplantations such as ABO and HLA-incompatible transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH): "allogenic response; allograft; immunosuppression; ABO incompatible transplantation; donor specific antibodies; HLA incompatible; desensitization; kidney transplantation". Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 4717 articles. After reading titles and abstracts, 141 were included in the text, based on their relevance.

RESULTS

The considerable step in comprehension and knowledge allogeneic response this last few years allowed a better used of immunosuppression and the discover of news immunosuppressive drugs. In the first part of this article, the allogeneic response will be described. The different classes of immunosuppressive drugs will be presented and the actual management of immunosuppression will be discussed. Eventually, the modalities and results of immunologically high-risk transplantations such as ABO and HLA incompatible transplantations will be reported.

CONCLUSIONS

The knowledge and the control of allogeneic response to allogeneic graft allowed the development of renal transplantation.

[Immunosuppression in kidney transplantation]

These last years, major progress in renal transplantation were observed, especially in immunosuppression with new drugs available. In the first part of this paper, immunological process of allogenic response is described. Then, the different classes of immunosuppressive drugs, their potential associations and new trends in immunosuppression are presented.

[Rejection of kidney graft: mechanism and prevention]

Rejection occurs after the introduction of a genetically different graft, in a recipient. Nowadays, it is still a major obstacle in renal transplantation and reflects a normal protective immune response of a recipient against a foreign antigen. Involving many mechanisms of the innate and adaptive immunity, this reaction results in renal parenchymal lesions witch may progress to graft destruction and loss of its function. Several ways are currently used to reduce the action of the immune system and consequently reduce the risk of rejection. After a presentation of the main actors and the sequence of events leading to rejection, we will describe the strategy used by antirejection teams' transplantation. We will successively consider the prevention (pre-transplant immunological assessment, preventive immunosuppressive therapy), the monitoring (search for antibodies, biopsies) and the treatment.