Belatacept in Kidney Transplantation: Are We Ready for a Different Immunosuppression Backbone?

Abstract

Calcineurin inhibitors (CNIs), cyclosporine and
tacrolimus, remain the backbone of immunosuppression
after kidney transplantation since the 1990s. However,
their Achilles heel remains the adverse effect profile
which has to be accepted and closely monitored to
prevent limitations to graft and patient survival. Chronic
allograft nephropathy, a term defining late graft failure
due to many factors is largely attributed to CNI related
nephrotoxicity [1]. Amongst CNIs, tacrolimus-based
regimens are more popular than cyclosporine due to less
nephrotoxicity and greater potency [2]. But tacrolimus in
turn is associated with more neurotoxic and
gastrointestinal side effects and higher rates of posttransplant diabetes mellitus than cyclosporine [3].
Furthermore, there are several direct and indirect
metabolic side effects of tacrolimus, affecting patient
survival due to cardiac events, a risk potentially far
greater than the risk of graft failure due to chronic
allograft nephropathy.