Best Practice for Immunosuppressive Therapy after Kidney Transplantation

Abstract

Despite significant advances in immunosuppressive therapy, immune rejection and opportunistic infections remain major challenges in kidney transplantation. This review outlines the best practices of immunosuppressive management at Hiroshima University. A key feature is the application of CFSE-based mixed lymphocyte reaction (MLR) for individualized immune monitoring. This assay quantitatively assesses donor-reactive T-cell responses and guides optimization of immunosuppressive regimens. We also discuss the clinical utility of Everolimus (mTOR inhibitor) combined with low-dose cyclosporine, which maintains renal function while reducing CMV infections. For ABO-incompatible transplantation, our protocol incorporates rituximab-based desensitization and plasmapheresis, achieving favorable outcomes. In elderly recipients, we found that although cyclosporine doses were lower, donor-specific T-cell responses remained preserved, warranting caution in dose reduction. Additionally, analysis of patients with CMV antigenemia revealed that donor-specific T-cell immunity was unaffected despite a systemic immunosuppressive trend, challenging the routine reduction of immunosuppression during CMV infection. Overall, personalized immunosuppressive strategies using functional immune assays such as CFSE-MLR may enhance long-term graft survival in kidney transplantation.