Calcineurin inhibitors in kidney transplantation: friend or foe?

Purpose of review The utilization of calcineurin inhibitors (CNI) in kidney transplantation has dramatically improved short-term outcomes but significant gains in long-term outcomes have proved elusive. Nephrotoxicity is the major problem associated with CNIs and is responsible for the disappointing progress seen in long-term graft survival. In this review, we assess CNI efficacy as well as the latest strategies employed to limit long-term CNI nephrotoxicity. Recent findings Three CNI sparing strategies - CNI withdrawal, CNI avoidance, and CNI minimization are evaluated with discussion of key studies such as the Efficacy Limiting Toxicity Elimination-Symphony and Spare-the-Nephron studies. Recent breakthroughs in transplant immunosuppression are discussed such as the BENEFIT and BENEFIT-EXT studies, which have led to the recent US Food and Drug Administratrion approval of belatacept, a novel T-cell costimulation blocker. Summary For now, CNIs remain the proven standard of care in modern immunosuppression. However, some novel agents may challenge the role CNIs play in kidney transplantation in the very near future.