Principles of Immunosuppression in the Management of Kidney Disease: Core Curriculum 2022

The management of immunosuppression utilized in glomerular diseases requires highly nuanced care. Timely recognition and management of these disorders is essential to mitigate the extent of kidney damage. This involves being cognizant of the various classes of immunosuppression, which includes alkylating agents, antimetabolites, calcineurin inhibitors, anti-CD20 therapy, complement inhibitors, corticosteroids, and intravenous immunoglobulin. The mechanisms of action of these drugs, along with associated pharmacokinetics and pharmacodynamics, facets of monitoring, and adverse effects are important aspects with which nephrologists are required to be well versed. In addition, an understanding of therapeutic decisions such as induction and maintenance regimens in the setting of glomerular disease and alteration based on trajectory of disease and subsequent response is imperative. The overarching principle of these strategies of immunosuppression is to achieve a balance of disease mitigation without exposure to inadvertent harm. Special groups such as pregnant women, elderly patients, and patients treated with dialysis are especially susceptible to immunosuppression and thus need highly weighed therapeutic strategies and enhanced surveillance of adverse effects.