Prophylaxis and treatment of T-cell- and antibody-mediated rejection

Background. Kidney transplantation is the treatment of choice for chronic renal failure. Despite significant progress in transplantation medicine, long-term survival of kidney transplants remains limited. This is mainly due to the cardiovascular and nephrotoxic side effects of the immunosuppressive therapy and uncontrolled acute and chronic rejection. Objective and methods. Selective literature review of the PubMed database for identification of new diagnostic tools for detection and classification of acute or chronic rejection. Additionally, a search for new therapeutic strategies to prevent or treat acute or chronic rejection. Results. The gold standard for the diagnosis and classification remains the histological evaluation of the kidney biopsy according to the BANFF criteria. A therapeutic option to improve long-term graft survival could be early steroid reduction. Whether steroid reduction improves long-term graft survival remains unclear; however, the probability of steroid-induced complications, such as new onset diabetes is reduced. Another option is immunosuppression without calcineurin inhibitor (CNI) using belatacept. For cellular rejection preferred treatment options remain high doses of steroids and antithymocyte globulin. For antibody-mediated and chronic rejection the treatment consists of plasmapheresis and immunoglobulins. Conclusion. The level of evidence for treatment of acute or chronic rejection is disappointing and limited. New substances, such as tocilizumab and the blockade of costimulators are on the horizon and could be urgently needed new therapeutic strategies.