Kidney fibrosis: origins and interventions.

All causes of renal allograft injury, when severe and/or sustained, can result in chronic histological damage of which interstitial fibrosis and tubular atrophy (IF/TA) are dominant features. Unless a specific disease process can be identified, what drives IF/TA progression in individual patients is often unclear. In general, clinicopathological factors known to predict and drive allograft fibrosis include graft quality, inflammation (whether 'nonspecific' or related to a specific diagnosis), infections such as polyomavirus-associated nephropathy, calcineurin inhibitors and genetic factors. The incidence and severity of chronic histological damage have decreased substantially over the last 3 decades, but it is difficult to disentangle what effects individual innovations (eg, better matching and preservation techniques, lower calcineurin inhibitor dosing, BK viremia screening) may have had. There is little evidence that CNI-sparing/minimization strategies, steroid minimization or renin-angiotensin-aldosterone system blockade result in better preservation of intermediate-term histology. Treatment of subclinical rejections has only proven beneficial to histological and functional outcome in studies in which the rate of subclinical rejection in the first 3 months was > 10-15%. Potential novel antifibrotic strategies include antagonists of transforming growth factor-[beta], connective tissue growth factor (CTGF), several tyrosine kinase ligands (EGF, PDGF, VEGF), endothelin and inhibitors of chemotaxis. Although many of these drugs are mainly being developed and marketed for oncological indications and diseases such as idiopathic pulmonary fibrosis, a number may hold promise in the treatment of diabetic nephropathy, which could eventually lead to applications in renal transplantation. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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