{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,26]],"date-time":"2026-10-26T20:01:47Z","timestamp":1793044907735,"version":"4.5.0"},"reference-count":221,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,1]]},"abstract":"<jats:p>Current maintenance immunosuppression commonly comprises a synergistic combination of tacrolimus as calcineurin inhibitor (CNI), mycophenolic acid, and glucocorticoids. Therapy is often individualized by steroid withdrawal or addition of belatacept or inhibitors of the mechanistic target of rapamycin. This review provides a comprehensive overview of their mode of action, focusing on the cellular immune system. The main pharmacological action of CNIs is suppression of the interleukin-2 pathway that leads to inhibition of T cell activation. Mycophenolic acid inhibits the purine pathway and subsequently diminishes T and B cell proliferation but also exerts a variety of effects on almost all immune cells, including inhibition of plasma cell activity. Glucocorticoids exert complex regulation via genomic and nongenomic mechanisms, acting mainly by downregulating proinflammatory cytokine signatures and cell signaling. Belatacept is potent in inhibiting B\/T cell interaction, preventing formation of antibodies; however, it lacks the potency of CNIs in preventing T cell\u2013mediated rejections. Mechanistic target of rapamycin inhibitors have strong antiproliferative activity on all cell types interfering with multiple metabolic pathways, partly explaining poor tolerability, whereas their superior effector T cell function might explain their benefits in the case of viral infections. Over the past decades, clinical and experimental studies provided a good overview on the underlying mechanisms of immunosuppressants. However, more data are needed to delineate the interaction between innate and adaptive immunity to better achieve tolerance and control of rejection. A better and more comprehensive understanding of the mechanistic reasons for failure of immunosuppressants, including individual risk\/benefit assessments, may permit improved patient stratification.<\/jats:p>","DOI":"10.1097\/tp.0000000000004646","type":"journal-article","created":{"date-parts":[[2023,6,13]],"date-time":"2023-06-13T00:00:40Z","timestamp":1686614440000},"page":"148-160","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":16,"title":["Cellular Immunobiology and Molecular Mechanisms in Alloimmunity\u2014Pathways of Immunosuppression"],"prefix":"10.1097","volume":"108","author":[{"given":"Eva","family":"Schrezenmeier","sequence":"first","affiliation":[{"name":"Department of Nephrology and Medical Intensive Care, Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Berlin, Germany."},{"name":"Berlin Institute of Health at Charit\u00e9 \u2013 Universita\u0308tsmedizin Berlin, BIH Academy, Clinician Scientist Program Universita\u0308tsmedizin Berlin, Berlin, Germany."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"D\u00f6rner","sequence":"additional","affiliation":[{"name":"Department of Rheumatology and Clinical Immunology \u2013 Universit\u00e4tsmedizin Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Berlin, Germany."},{"name":"Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fabian","family":"Halleck","sequence":"additional","affiliation":[{"name":"Department of Nephrology and Medical Intensive Care, Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Berlin, Germany."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Klemens","family":"Budde","sequence":"additional","affiliation":[{"name":"Department of Nephrology and Medical Intensive Care, Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Berlin, Germany."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2023,12,13]]},"reference":[{"key":"R1-20250604","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1038\/s41584-020-0374-8","article-title":"Mycophenolate mofetil, azathioprine and tacrolimus: mechanisms in rheumatology.","volume":"16","author":"Broen","year":"2020","journal-title":"Nat Rev Rheumatol"},{"key":"R2-20250604","doi-asserted-by":"crossref","first-page":"4183","DOI":"10.1002\/jcp.29369","article-title":"An update on potentials and promises of T cell co-signaling molecules in 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