CAR-T cell therapy in nephrology

In recent years, chimeric antigen receptor T-cell (CAR-T) therapy has emerged as a promising immunotherapeutic strategy beyond oncology, offering new treatment opportunities for immune-mediated kidney diseases. These conditions including systemic lupus erythematosus, ANCA-associated vasculitis, membranous nephropathy, and monoclonal gammopathy-related nephropathies are characterized by dysregulated B cell and plasma cell activity that often proves refractory to standard immunosuppression. CAR-T cells, engineered to target antigens such as CD19 or BCMA, enable potent and durable depletion of pathogenic lymphocyte subsets, with growing evidence of clinical efficacy in autoimmune settings. Recent clinical data suggest that CAR-T therapies can induce profound immunological remission, restore immune tolerance, and improve renal outcomes. Novel platforms such as chimeric autoantibody receptor (CAAR)-T cells and bispecific T-cell engagers (BiTEs) further refine antigen targeting and may offer scalable alternatives. Importantly, early studies also point to the potential use of these therapies in kidney transplantation, particularly desensitization therapy in highly sensitized patients and treatment of post-transplant lymphoproliferative disorders. Despite these advances, challenges remain regarding toxicity, patient selection, cost, and long-term safety. This review critically evaluates the current landscape of CAR-based therapies in nephrology, explores their immunopathological rationale, and outlines future directions for their integration into clinical practice.