One-year graft survival of renal grafts increased progressively in the last two decades and can be now considered excellent, but long-term outcomes has not improved proportionally in the last years. Indeed, chronic allograft dysfunction is a growing problem among renal transplant recipients and together with death from cardiovascular disease, infection and malignancy is the leading cause of graft failure.
The goal of immunosuppressive therapy is to balance the beneficial effects of reducing acute rejection while minimizing adverse effects from over-immunosuppression such as infections, malignancy, and cardiovascular disease. Current immunosuppressive protocols use combinations of immunosuppressive drugs with different mechanisms of action to maximize efficacy and minimize the toxicity of each drug. During the past decade, there has been a increasing interest in identifying regimens that may allow the minimization of immunosuppressive drugs characterized by significant side effects, including nephrotoxicity and metabolic dysregulation. The emergence of new immunosuppressive agents and tolerance protocols appears promising as a means to deliver immunosuppression without long-term toxicity. Ultimately, the goal of “future” immunosuppression is to move from an empiric therapy to a personalized treatment.