Minimizationvstailoring: Where do we stand with personalized immunosuppression during renal transplantation in 2015?

Abstract

The introduction of novel immunosuppressive agents over the last two decades and the improvement of our diagnostic tools for early detection of antibodymediated injury offer us an opportunity, if not a mandate, to better match the immunosuppression needs of the individual patients with side effects of the therapy. However, immunosuppressive regimens in the majority of programs remain mostly protocol-driven, with relatively little inter-program heterogeneity in certain areas of the world. Emerging data showing different outcomes with a particular immunosuppressive strategy in populations with varying immunological risks underscore a real potential for "personalized medicine" in renal transplantation. Studies demonstrating marked differences in the adverse-effect profiles of individual drugs including the risk for viral infections, malignancy and renal toxicity call for a paradigm shift away from a "one size fits all" approach to an individually tailored immunosuppressive therapy for renal transplant recipients, assisted by both screening for predictors of graft loss and paying close attention to dose or class-related adverse effects. Our paper explores some of the opportunities during the care of these patients. Potential areas of improvements may include: (1) a thorough assessment of immunological and metabolic risk profile of each renal transplant recipient; (2) screening for predictors of graft loss and early signs of antibody-mediated rejection with donor-specific antibodies, protocol biopsies and proteinuria (including close follow up of adverse effects with dose adjustments or conversions as necessary); and (3) increased awareness of the possible link between poor tolerance of a given drug at a given dose and non-adherence with the prescribed regimen. Altogether, these considerations may enable the most effective use of the drugs we already

Risk factors for fracture in adult kidney transplant recipients

“…It is important to note that a previous study found that kidney transplant recipients who received early corticosteroid withdrawal had a 1.6% reduction in fracture compared to recipients who received standard corticosteroid based immunosuppression [43] . Future studies should explore this further, including measuring glucocorticoid use as a continuous variable and assessing the impact of reduced dose on fracture risk, with a consideration given to the impact this may have on long-term immunological outcomes (e.g., graft loss) [44] . Second, we were unable to assess several risk factors, such as body mass index and estimated glomerular filtration rate, due to a high proportion of missingness (> 50%).…”

Management considerations in the failing renal allograft

“…Calcineurin inhibitors are associated with an increased risk of hypertension, new‐onset diabetes after transplantation (NODAT), and dyslipidaemia, and are implicated in endothelial dysfunction and GFR impairment . Corticosteroids are associated with dyslipidaemia, NODAT, hypertension, metabolic bone disease, and accelerated atherosclerotic vascular disease …”

Eredményeink a teljes jogú Eurotransplant-tagság óta. A Debreceni Vesetranszplantációs Központ tapasztalatai

“…Ami jelenleg biztonsággal kijelenthető, hogy a magasabb kockázatú donorok és recipiensek párosításával végzett veseátültetések eredményei rövid távon nem rosszabbak a korábbi időszakban mért adatokhoz képest, azaz az esetszám biztonsággal növelhető a korábban marginális-nak (ECD) tekintett donorok és nem ideálisnak tartott recipiensek elfogadásával, a megfelelő perioperatív ellá-tás, immunszuppresszió és személyre szabott kezelés mellett [35]. A betegek edukációja, a megfelelő ismeretterjesztés [36] és a nefrológiai ellátásban részt vevő kollégákkal fenntartott, nyílt, konzultatív és konstruktív kapcsolat alapján várható a várólistára referált betegek arányának növekedése a jelenlegi 10-13%-ról akár 20%-ra, az élődonoros program részarányának növekedésével együtt.…”