Basics of immunosuppression in kidney transplantation

1. BASICS OF IMMUNOSUPPRESSION
IN KIDNEY TRANSPLANTATION
Ahmed Donia, MD, MRCP (UK)
Consultant of nephrology
Urology and nephrology center
Mansoura University, Egypt

2. WHY NEEDED?
WHICH PROTOCOL TO USE?
HOW DOES IT WORK?
WHAT DOES IT COST?

3. WHY NEEDED?
WHICH PROTOCOL TO USE?
HOW DOES IT WORK?
WHAT DOES IT COST?

4. WHY NEEDED?

5. WHY NEEDED?

6. WHY NEEDED?
HLA

7. WHY NEEDED?
HLA

8. WHY NEEDED?
HLA
WBC

9. WHY NEEDED?
HLA
WBC Self organ
HLA

10. WHY NEEDED?
HLA
WBC Self organ
HLA
√

11. WHY NEEDED?
HLA
WBC
Transplanted organ
HLA

12. WHY NEEDED?
HLA
WBC
Transplanted organ
HLA
REJECTION

13. WHY NEEDED?
HLA
WBC Transplanted organ
HLA
REJECTION
IMMUNOSUPPRESSION

14. WHY NEEDED?
WHICH PROTOCOL TO USE?
HOW DOES IT WORK?
WHAT DOES IT COST?

15. HOW DOES IT WORK?

16. HOW DOES IT WORK?

17. HOW DOES IT WORK?

18. HOW DOES IT WORK?

19. HLA
WBC Transplanted organ
HLA
REJECTION
IMMUNOSUPPRESSION
HOW DOES IT WORK?

20. HOW DOES IT WORK?

21. HOW DOES IT WORK?
Signal 1

22. HOW DOES IT WORK?
Signal 2
Signal 1

23. HOW DOES IT WORK?
Signal 2
Signal 1
Signal 3

24. HOW DOES IT WORK?

25. HOW DOES IT WORK?
PLASMA
EXCHANGE
RITUXIMAB
IV Ig

26. WHY NEEDED?
WHICH PROTOCOL TO USE?
HOW DOES IT WORK?
WHAT DOES IT COST?

27. WHICH PROTOCOL TO USE?

28. TIME AFTER TRANSPLANTATION
WHICH PROTOCOL TO USE?

29. TIME AFTER TRANSPLANTATION
INDUCTION
WHICH PROTOCOL TO USE?

30. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE?

31. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
GRAFTFUNCTION
WHICH PROTOCOL TO USE?

32. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
GRAFTFUNCTION
ANTIREJECTION
ANTIREJECTION
WHICH PROTOCOL TO USE?

33. INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
ANTIREJECTION
ANTIREJECTION
WHICH PROTOCOL TO USE?

34. WHICH PROTOCOL TO USE?

35. THE OPTIMAL IMMUNOSUPPRESSION
PROTOCOL IS UNCLEAR
WHICH PROTOCOL TO USE?

36. THE OPTIMAL IMMUNOSUPPRESSION
PROTOCOL IS UNCLEAR
CENTER/PATIENT-ADAPTED PROTOCOLS
WHICH PROTOCOL TO USE?

37. THE OPTIMAL IMMUNOSUPPRESSION
PROTOCOL IS UNCLEAR
CENTER/PATIENT-ADAPTED PROTOCOLS
WHICH PROTOCOL TO USE?
DRUG DOSES ↓GRADUALLY WITH TIME

38. WHICH PROTOCOL TO USE?

39. WHICH PROTOCOL TO USE?

40. TIME AFTER TRANSPLANTATION
INDUCTION
WHICH PROTOCOL TO USE?

41. TIME AFTER TRANSPLANTATION
INDUCTION
WHICH PROTOCOL TO USE?

42. TIME AFTER TRANSPLANTATION
INDUCTION
WHICH PROTOCOL TO USE?

43. TIME AFTER TRANSPLANTATION
INDUCTION
High risk patients
• High PRA
• Donor specific antibodies
• 5-6 HLA mismatch
• Multiple previous transplants
• Previous transplant lost due to
immunologic cause
WHICH PROTOCOL TO USE?

48. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE?

49. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE?

52. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE?

53. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE?

55. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE?

56. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE?

60. TIME AFTER TRANSPLANTATION
INDUCTION
MAINTENANCE IMMUNOSUPPRESSION
GRAFTFUNCTION
ANTIREJECTION
ANTIREJECTION
WHICH PROTOCOL TO USE?

61. TYPES OF REJECTION
WHICH PROTOCOL TO USE?

62. TYPES OF REJECTION
ACUTE CHRONIC
CELLULAR HUMORAL CELLULAR HUMORAL
WHICH PROTOCOL TO USE?

63. TYPES OF REJECTION
ACUTE
CELLULAR HUMORAL
WHICH PROTOCOL TO USE?

64. ANTI-REJECTION PROTOCOL
ACUTE
CELLULAR HUMORAL
WHICH PROTOCOL TO USE?

65. ACUTE
CELLULAR HUMORAL
WHICH PROTOCOL TO USE?
ANTI-REJECTION PROTOCOL

66. DRUG MONITORING
WHICH PROTOCOL TO USE?

67. DRUG MONITORING
WHICH PROTOCOL TO USE?

68. DRUG MONITORING
WHICH PROTOCOL TO USE?

69. DRUG MONITORING
WHICH PROTOCOL TO USE?

70. WHICH PROTOCOL TO USE?

71. WHICH PROTOCOL TO USE?

72. WHY NEEDED?
WHICH PROTOCOL TO USE?
HOW DOES IT WORK?
WHAT DOES IT COST?

73. WHAT DOES IT COST?

74. WHAT DOES IT COST?
IMMUNE SYSTEM

75. WHAT DOES IT COST?
IMMUNE SYSTEM

76. WHAT DOES IT COST?
IMMUNE SYSTEM
INFECTION

77. WHAT DOES IT COST?
IMMUNE SYSTEM
INFECTION
MALIGNANCY

78. Transplantation. 2008 Oct 27;86(8):1139-42. doi: 10.1097/TP.0b013e318187ccb3.
Postkidney transplant malignancy in Egypt has a unique pattern: a three-decade experience.
Donia AF, Mostafa A, Refaie H, El-Baz M, Kamal MM, Ghoneim MA.
Source
Urology and Nephrology Center, Mansoura University, Egypt.
Abstract
The pattern of posttransplant malignancy varies among transplant units. We report on our
single-center experience. Between 1976 and 2007, 1866 kidney transplantations were carried
out (1390 males and 476 females, mean age 29.84+/-10.47 years). Recipients who developed
posttransplant malignancy were evaluated (74 patients, 3.97%). Furthermore, their data were
compared with those of the malignancy-free recipients (1792 patients). Kaposi sarcoma was
the commonest type (36.8%) and had the shortest transplant-to-malignancy period (mean
2.84 years). The lesions were only cutaneous in 75% of cases. Skin cancers were the fourth
among posttransplant malignancies (9.2%) and 85.7% of cases were basal cell carcinoma. In
our series, age and prior blood transfusion were identified as independent risk factors for the
development of posttransplant malignancy. In conclusion, the prevalence and type of
posttransplant malignancy vary because of many factors including environmental and genetic
factors. In our series, Kaposi sarcoma was the commonest type and, therefore, needs further
evaluation.

79. WHAT DOES IT COST?
HYPERTENSION

80. WHAT DOES IT COST?
ELECTROLYTE DISTURBANCES

81. WHAT DOES IT COST?
NEUROPSYCHIATRIC PROBLEMS

82. WHAT DOES IT COST?
NEPHROTOXICITY

83. WHAT DOES IT COST?
COSMETIC CHANGES

84. WHAT DOES IT COST?
DIABETES MELLITUS

85. WHAT DOES IT COST?
GIT PROBLEMS

86. WHAT DOES IT COST?
DELAYED HEALING

87. WHAT DOES IT COST?
DYSLIPIDEMIA

88. WHAT DOES IT COST?
MYELOSUPPRESSION

89. WHAT DOES IT COST?
TERATOGENICITY

90. WHAT DOES IT COST?
HEPATOTOXICITY

91. WHAT DOES IT COST?
BONE DISEASE
EYE PROBLEMS

92. • Immunosuppression is permanently needed
post-kidney transplantation to prevent/treat
rejection. Doses gradually ↓ with time
• Combined protocol (usually triple) is used
• Infection and malignancy are general potential
untoward effects in addition to drug-specific
side effects
• Judicious handling is ,therefore, needed
TAKE HOME MESSAGE

93. THANK YOU
MANSOURA CITY
UROLOGY AND NEPHROLOGY CENTER
MANSOURA UNIVERSITY