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More than fifty years after the success of the two first renal transplantations in Boston and in Necker hospital in Paris, renal transplantation became the treatment of choice of end stage renal failure, because it improves not only the quality of life of the patients but also their long-term survival. In France, more than 3,700 kidney transplantations are performed every year and more than 40,000 patients are living with a functioning kidney allograft. This treatment of end stage renal disease requires a fine-tuned pre-transplant evaluation and a multidisciplinary post-transplant care in order to prevent, to detect and to treat comorbidities and complications of immunosuppression. The ambition of this manuscript is not to describe in an exhaustive way all the aspects of renal transplantation but starting from the experience of a team, recently published data, and national and international guidelines, to try to provide a synthetic and chronological view of the early post-transplant monitoring., (Copyright © 2019. Published by Elsevier Masson SAS.)

Three pilot studies have offered proof-of-concept that operational tolerance can be induced through mixed chimerism in recipients of combined kidney and hematopoietic cell transplants from the same donor. In two studies, sustained mixed chimerism was induced allowing safe and rejection-free immunosuppression withdrawal. However, this success came at heavy toll, requiring harsh cytoreductive regimen and a balance tipped toward graft-versus-host reactivity. Hence, achievement of durable chimerism in humans is not devoid of a significant risk of graft-versus-host disease. In contrast, transient mixed chimerism can be induced with non-myeloablative and a less cytotoxic regimen, leading to transplant tolerance, whose underpinning mechanisms are more complex, involving T cell exhaustion, peripheral deletion and suppression., (Copyright © 2017 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.)

Renal transplantation is the treatment of choice of end stage renal failure. It both improves the quality and the quantity of life compared to other techniques, such as hemodialysis. These results are partly related to the use of immunosuppressive therapy more effective and whose handling has improved over time. Advances in understanding the mechanisms of lymphocyte activation and the phenomena of rejection have in fact better defined the use of these treatments and their associations. Treatments can be broadly classified according to their characteristics (biological or chemical). Among chemical treatments, steroids are widely used, although the question of their avoidance or spearing is still a matter of debate. The cornerstone of immunosuppressive regimens remains the calcineurin inhibitors, characterized by a narrow therapeutic index and the need for therapeutic drug monitoring. Inhibitors of mammalian target of rapamycin (mTOR) have interesting antiproliferative effects that could be important against chronic allograft dysfunction and/or carcinogenesis. However, their safety profile makes them difficult to handle. Inhibitors of purine synthesis are largely based on inhibitors of inosine monophosphate dehydrogenase (IMPDH). Their effectiveness makes them privileged partners of other therapeutic classes. Among biological treatments, it is possible to separate the depleting and non depleting antibodies. Among the former, antithymocyte globulins are mainly active in T cells, whereas rituximab, a monoclonal anti-CD20, is active in B cells involved in the phenomena of humoral rejection. The non depleting antibodies are represented by anti-CD25, directed against the receptor for interleukin-2. In the near future it is likely that the belatacept, a costimulation blockade fusion protein will be used to allow calcineurin inhibitors sparing. Other immunosuppressive agents, acting at different levels of the immune response are being evaluated. In addition, advances in pharmacology offered hope of a better individualization of immunosuppressive therapies and better definition of therapeutic strategies used., (Copyright © 2011. Published by Elsevier SAS.)