Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and International Society for Heart and Lung Transplantation: An executive summary

Abstract

Advances in maintenance immunosuppression over the past three decades have improved solid organ transplantation outcomes dramatically. Uninterrupted access to immunosuppression is paramount to minimize rejection and maintain allograft and patient survival. Agents used vary based on transplanted organ, center-specific protocol, provider expertise, insurance formularies, ability to cover co-pays, recipient characteristics and tolerability. Published data reflects this heterogeneity. Despite these obstacles, the information about maintenance immunosuppression use cross pollinates between organ groups with standard of care agents often being used offlabel, making medication access a challenge for many transplant recipients. A multidisciplinary panel of American transplant clinicians was formed to review published literature on maintenance immunosuppression with the goal to formulate consensus

Tacrolimus’s Time Below Therapeutic Range Is Associated With Acute Pancreatic Graft Rejection and the Development of De Novo Donor-specific Antibodies

“…Tacrolimus is a crucial part of maintenance immunosuppression in pancreas transplantation and is recommended by current guidelines despite being prescribed off-label due to lack of approval by the US Food and Drug Administration. However, sufficient evidence has proven its efficacy in improving short- and long-term pancreatic graft survival [ 34 ]. There is some data on specific dosing of immunosuppressors and dnDSA formation in pancreas transplantation.…”

Off-Label Immunosuppressant Drugs in Solid Organ Transplantation

“…In 2022, Nelson et al published a consensus with recommendations related to the use of maintenance immunosuppression in SOT [2]. This document reflected, for the different SOT modalities, which drugs were most commonly used as maintenance immunosuppressive therapy.…”

PD-L1’s Role in Preventing Alloreactive T Cell Responses Following Hematopoietic and Organ Transplant

“…Additionally, the potential adverse effects of PD-L1-induced immunosuppression must be viewed in the context of the current gold standard of post-transplant and GVHD immunosuppressive therapies, such as calcineurin inhibitors and corticosteroids. The high rates of infection in post-transplant patients due to immunosuppression are already well understood [ 4 , 138 ]. This is especially evident in the occurrence of viral reactivation.…”

“…In acute rejection, TCRs instead identify whole human leukocyte antigen (HLA) molecules presented by the donor cells as foreign. Due to these rejection processes, almost all organ transplants have limited life spans, requiring immunosuppressive therapy in recipients to prolong their graft’s viability [ 3 , 4 ].…”