Immunosuppression regimens that can be used for Renal transplant

1. Immunosuppression In Renal Transplant
Dr. Rabia Saleem Safdar
MBBS, FCPS( General Pediatrics)
Fellow of Pediatric Nephrology
Nishtar Medical University & Hospital Multan
Rotational Trainee at Kidney Transplant Sheikh zayed Hospital
1

2. Specific Learning Outcomes
• What is immunosuppression?
• Why it is needed?
• How allogeneic reaction occurs?
• Which are the approved immunosuppressive agents?
• How immunosuppression work and their major side effects?
• What are the general principles of Immunosuppressive Treatment?
• What are the phases of induction?
• Which Protocol to use?
• What does it cost?
• Novel drugs
• Innovative Protocols in Renal transplant
• Pediatric Immunosuppression protocols
2

3. Immunosuppression
Immunosuppression involves an act that
reduces the activation or efficacy of immune
system
3

4. Immunosuppressant
• Any agent that causes immunosuppression
• Can be dugs or environmental agents
4

5. Why needed?
WBC
HLA
HLA
Self Organ
✔
5

6. Why needed?
WBC
HLA
HLA
Non-Self
Organ
REJECTION
✖
IMMUNOSUPPRESSION
6

7. Allorecognition ( Activation of T cell & B cell)
Recognition of foreign HLA antigen by recipient T cell
Two pathways:
Direct Pathway
(1) Activated T cells with directly interact with MHC molecule–peptide complexes on
donor antigen presenting cells (APCs) and induce donor cell apoptosis through cellular
rejection
Indirect Pathway
(2) Donor peptides bound to self-derived MHC molecule peptide complexes
processed by recipient APCs are recognized by recipient T cells and then cause
allograft destruction
7

8. Allorecognition
8

9. T-cell activation
Three signal activate T cell
Signal 1 :TCR signaling
• TCR-CD3complex on CD4+ T cells
Signal 2 :Co-stimulation
• Interaction between B7.1 (CD80) or
B7.2(CD86) in APCs and CD28 molecules in
T cells
• Signaling pathways activated
 calcineurin pathway
 renin–angiotensin system (RAS)/mitogen
activated protein (MAP) kinase
 nuclear factor kappa B (NFκB)
 inhibitor of NFκB kinase (IKK) pathway
Signal 3 : Differentiation
Cytokines released from APCs cause
differentiation of T cell subsets and
proliferation by activation of
 Janus kinase protein JAK 3
 mTOR pathway
Leads to cell cycling and proliferation by purine
synthesis 9

10. 10

11. B cell activation
• Two signal processes
Signal 1
Macrophage captures the antigen
BCR on B cell form a immulogical synapse
• Antigen internalization
• Downstream signaling Calcineurin and mTOR
pathway
Antigen is then presented to the surface of B cell
with MHC II
Signal 2
Naïve B cell are activated with the help of follicular
helper T (Tfh) cells, which initiate cell co-stimulation
interactions that produce cytokine
The activated B cells migrate into the germinal center
where some of them differentiate into memory B cells
or plasmablasts.
Plasmablasts differentiate into long-lived plasma cells
on bone marrow, which can secrete high-affinity
donor-specific antibodies that participate in antibody-
mediated rejection 11

12. B cell activation
12

13. Approved Immunosuppresive Agents
• Glucocortcoids
• Small molecule drugs
Calcineurin inhibitors
Cyclophilin-binding drugs: cyclosporine
FKBP12-binding drugs: tacrolimus
Target-of-rapamycin inhibitors: sirolimus, everolimus
Inhibitors of nucleotide synthesis
Purine synthesis inhibitors Mycophenolate mofetil
Antimetabolites: Azathioprine
• Protein drugs
Depleting antibodies (against T cells, B cells, or both)
Polyclonal antibody: Antithymocyte globulin
Monoclonal anti-CD3 antibody Muromonab
anti-CD52 antibody Alemtuzumab
Depleting antibodies (B cells)
Monoclonal anti-CD20 antibody Rituximab
Non-depleting antibodies
Monoclonal anti-CD25 antibody Daclizumab, Basiliximab
• Intravenous immune globulin
13

14. Corticosteroids
• Corticosteroids have been used to suppress inflammation and immune-mediated
diseases for nearly half a century.
• Corticosteroids possess both immunosuppressive and anti-inflammatory
properties.
• Wide range of effects on many phases of the immune and inflammatory responses
inhibition of cytokine production
 Reduction of adhesion molecule expression
 Induction of lymphocytes apoptosis
 Suppression of inflammatory cell activation
Corticosteroids are used for both maintenance immunosuppression as well as for the
treatment of acute rejection episodes.
14

15. Corticosteroids
Methylprednisolone
• A large dose of methylprednisolone is still typically given intraoperatively in a
dose of up to 500 mg. In standard protocols, the dose is then reduced rapidly
from 500 mg on day 1 to 125mg on day 5
• Given in 100ml Normal saline 0.9% over 30min
Prednisolone
Usually started 6th POD
• The maximal oral dose of prednisone at 1 month should be 30 mg
• and 5 to 10 mg at 3 months
• The long- term maintenance dose is 5 mg
• Consider complete withdrawl
15

16. 16
Cardiovascular Risk
(increase BP,Increase lipids)
Increase NODAT
Osteoprosis

17. Small molecule drugs- Calcineurin inhibitors
DRUG Description Mechanism Toxicity and
Comments
Cyclosporine
(Neoral )
11-amino-acid
cyclic peptide from
Tolypo-
cladium inflatum
Binds to
cyclophilin;
complex inhibits
calcineurin
phosphatase and T-
cell activation
Nephrotoxicity,
hemolytic–uremic
syndrome,
hypertension,
neurotoxicity, gum
hyperplasia, skin
changes, hirsutism,
post-
transplantation
diabetes mellitus,
hyperlipidemia;
Trough monitoring
required
17

18. DRUG Description Mechanism Toxicity and Comments
Tacrolimus
(FK506)
Macrolide antibiotic
from Streptomyces
Tsukubaensis
Binds to FKBP12;
complex inhibits
calcineurin
phosphatase and T-
cell activation
Effects similar to
cyclosporine
Lower incidence of
hypertension,
hyperlipidemia, skin changes,
hirsutism, and gum
hyperplasia
Higher incidence of post-
transplantation diabetes
mellitus and neurotoxicity
Trough monitoring required
m-TOR inhibitors
Sirolimus
(rapamycin)
Triene macrolide
antibiotic from S.
hygroscopicus
Binds to FKBP12;
complex inhibits
target of rapamycin
and interleukin-2–
driven T-cell
proliferation
Hyperlipidemia, Increased
toxicity of calcineurin
inhibitors,
thrombocytopenia, delayed
wound healing, delayed graft
function, mouth ulcers,
pneumonitis, interstitial lung
disease.
Lipid monitoring required.
18

19. Inhibitors of nucleotide synthesis
DRUG Description Mechanism Toxicity and
Comments
Mycophenolate
mofetil
a semisynthetic
“prodrug”
derivative of
mycophenolic acid
(the active form)
Inhibits synthesis of
guanosine
monophosphate
nucleotides; blocks
purine synthesis,
preventing
proliferation of T
and B cells
Gastrointestinal
symptoms (mainly
diarrhea), neutro-
penia, mild anemia;
blood-level
monitoring not re-
quired but may
improve efficacy;
absorption reduced
by cyclosporine
19

20. Antimetabolites
Drug Description Mechanism Toxicity and
Comments
Azathioprine Pro-drug that
releases 6-
mercaptopurine
Converts 6-
mercaptopurine to
tissue inhibitor of
metalloproteinase,
which is converted
to thioguanine
nucleotides that
interfere with DNA
synthesis;
thioguanine
derivatives may
inhibit purine
synthesis
Leukopenia, bone
marrow depression,
macrocytosis.
Blood-count
monitoring
required
20

21. 21

22. Protein Drugs
Drug Description Mechanism Toxicity and
Comments
Poly-clonal Anti-
thymocyte globulin
Polyclonal IgG from
horses or rabbits
immunized with human
thymo- cytes; absorbed
to reduce unwant- ed
antibodies
Blocks T-cell membrane
proteins (CD2, CD3,
CD45, and so forth),
causing altered function,
lysis, and prolonged T-cell
depletion
The cytokine-release
syndrome (fever, chills,
hypotension),
thrombocytopenia,
leukopenia, serum
sickness
Monoclonal Antibody
Muromonab-CD3
Murine monoclonal
antibody against CD3
component of T-cell–
recep- tor signal-
transduction complex
Binds to CD3 associated
with T-cell receptor,
leading to initial
activation and cytokine
release, followed by
blockade of function,
lysis, and T-cell depletion
Severe cytokine-release
syndrome, pulmonary
edema, acute renal fail-
ure, gastrointestinal
disturbances, changes in
central nervous system
Monoclonal
Anti CD 52 antibody
Alemtuzumab
Humanized monoclonal
antibody against CD52, a
25-to-29-kD
membrane protein
Binds to CD52 on all B
and T cells, most
monocytes,
macrophages, and natu-
ral killer cells, causing cell
lysis and prolonged
depletion
Mild cytokine-release
syndrome, neutropenia,
anemia, idiosyncratic
pancytopenia,
autoimmune thrombo-
cytopenia, thyroid
disease 22

23. DRUG Description Mechanism Toxicity and
Comments
Depleting antibodies (B
cells)
Monoclonal anti-CD20
antibody
Rituximab
Chimeric monoclonal
antibody against
membrane-spanning
four-domain protein
CD20
Binds to CD20 on B cells
and mediates
B-cell lysis
Infusion reactions,
hypersensitivity
Infusion reactions,
hypersensitivity
Non-depleting
antibodies
Monoclonal anti-CD25
antibody Basiliximab
Chimeric monoclonal
antibody against CD25
(interleukin-2–
receptor a chain)
Binds to and blocks the
interleukin-2– receptor a
chain (CD25 antigen) on
activated T cells,
depleting them and
inhibiting interleukin-2–
induced T-cell activation
Hypersensitivity reactions
(uncommon); two doses
required; no monitoring
required
Daclizumab Humanized monoclonal
antibody against CD25
(interleukin-2–
receptor a chain)
Has similar action to that
of basiliximab
Hypersensitivity reactions
(uncommon); five doses
recommended but two
may suffice; no
monitoring required
23

24. 24

25. Three General Principles of
Immunosuppressive Treatment
• Suppression is more likely to be achieved if therapy begins before exposure to
immunogen
• Immune reactivity & the likelihood of graft rejection are highest initially and
decrease over time
• Use low doses of several drugs with non-overlapping toxicities
• Avoid over-immunosuppression which increases susceptibility to infection and
malignancy
25

26. Phases of Immunosupression
Induction
• T cells are the primary mediators of rejection.
• A brief period of therapy with a potent immunosuppressive drug is used.
• Agent causes T cell depletion, and interrupt T cell activation & proliferation.
Maintenance
• Combination of low doses of drugs with non-overlapping toxicities is used to
prevent rejection of the allograft.
• The efficacy and safety of different agents used for chronic therapy is constantly
being evaluated.
• Agents are used throughout the patient's life.
26

27. Standardized Immunesuppression
Induction Agenets Maintainance agents Rescue agents
Depleting antibodies (against T
cells, B cells, or both)
Polyclonal antibody:
Antithymocyte globulin
Monoclonal
Anti-CD3 antibody OKT3
Muromonab
Anti-
CD52 antibody
Alemtuzumab
Depleting antibodies (B cells)
Monoclonal anti-CD20 antibody:
Rituximab
Calcineurin inhibitors
Cyclophilin-binding drugs:
cyclosporine
FKBP12-binding drugs: tacrolimus
Mild to moderate Rejections
Corticosteroids
Non-depleting antibodies
Monoclonal anti-CD25 antibody
Daclizumab, Basiliximab
Target-of-rapamycin inhibitors:
sirolimus, everolimus
Moderate to sever rejections
ATG
OKT3
Poly & Monoclonal Ab
Methyl prednisolone
IVIG
Inhibitors of nucleotide synthesis
Purine synthesis inhibitors
Mycophenolate mofetil
Antimetabolites: Azathioprine
Acute Ab mediated rejections
Immunoglobulins
Rituximab
Bortezomab
Eculizumab 27

28. What are the Therapies used?
INDUCTION THERAPY
Reduction in
Acute
rejection
Reduction in
components
of other IS
Improvement
in long term
graft function
28

29. Induction phase
• Induction refers to a brief period of intense IS given at the time of the transplant to prevent
early AR
• Depleting or non-depleting anti-T-cell antibodies PLUS
• Higher-dose of maintenance agents
29

30. Depleting or non-depleting anti-T-cell
antibodies
Induction agent Dose Schedule
Antithymocyte globulin 1.5 mg/kg
(80mg/m2)
Children
Postoperative 1, 3 , 5 days or daily dose for
3 to 5 days
Daclizumab 1mg/kg Within 24 hours post transplant plus
additional 4 doses fornightly after surgery
Basiliximab 20mg 2 hrs prior to transplant,followed by
2nd dose POD4.
Do not give Thymoglobulin if there is untreated infection, ↓platelets or ↓WCC
Pre-medication. 60 minutes before each dose of Thymoglobulin give:
IV hydrocortisone 100mg
IV H1 antagonist, for example chlorpheniramine 10mg • PO paracetamol 1000mg
Ensure prophylaxis against PCP, CMV and oral candidiasis.
30

31. ATG Basiliximab
Description Polycolonal Ab Monocolonal Ab
Mechanism T cell suppression Anti CD 25 Ab
Used in rejection Yes No
Dose 1.5 mg/kg given in a
course lasting 4 to 10 days
20mg Pre transplant then
again on day 4
31

32. EFFICACY
However, there is no evidence that Thymoglobulin improves long-term patient
or graft survival.
Randomized trials comparing Thymoglobulin with basiliximab demonstrate
either equivalent efficacy, or ↓AR with Thymoglobulin (15% vs 25% 1-year AR in
the largest study).
Thymoglobulin is at least as effective as other induction agents in preventing
acute rejection.
Alemtuzumab is not licensed for use in transplantation. The optimum dose for use as
induction therapy is not known.
• Current practice is to give either a single 30mg intra-operative / postoperative dose, or to give 30mg intra-
operatively and a second 30mg dose 24 hours later.
• There is little experience of alemtuzumab in treating AR, or in children.
32

33. • Higher-dose maintenance agents (the combination of oral IS drugs given at the
time of transplantation is often referred to as primary or de novo
immunosuppression)
33

34. Maintenance Drugs
Multiple drug therapy using combinations of two or three
• A calcineurin inhibitor
• An anti-metabolite
• Corticosteroids
• mTOR inhibitors
sirolimus or everolimus) (in place of a calcineurin inhibitor or antimetabolite)
Cyclosporine
Tacrolimus
Azathioprine
Mycophenolate mofetil
Prednisone
Sirolimus/Everolimus
34

35. Drugs Doses Schedule
Ciclosporine 7mg/kg in 2 divided doses Divided 12 hourly
Target
0–6 months 200– 250ng/mL
6–12 month 150– 200ng/mL
>12 months 80–150ngm/L
Tacrolimus 0.1–0.2mg/kg
0.2–0.3mg/kg Pediatric
Divided 12 hourly
Target
0–6 months 8–12ng/ml
6–12 months 6–10ng/ml
>12 months 4–8ng/ml
Mycophenolate Mofetil 1000mg
600mg/m2 Pediatric
12 hourly
Azathioprine 1.5–2mg/kg Once daily
Monitored by FBC, initially weekly,
then monthly. ↓ AZA dose if total
WCC <4.0x109/L, and suspend
therapy if neutropaenic (<2x109/L)
Sirolimus Single Loading dose 6 or 12mg
followed 24 hours later by a
once daily maintenance dose
of 2–4mg
Once daily
Target
0–6 months post-transplant 8–
12ng/ml
>6 months post transplant 6–10
ng/ml
MAINTAINANCE
DRUGS
35

36. Comparison between CNIs
Cyclosporine Tacrolimus
Bioavalability after PO dose 30-40% 88%
Metabolism Enteric & Liver Enteric & Liver
Distribution >99% bound to plasma
proteins & erythrocytes
>99% bound to plasma
proteins & erythrocytes
36
Glucose
intolerance
Neurotoxicity
Nephrotoxic
Hyperlipidemia
Cosmetic
GI effects
Hypertension

37. Drugs that Decrease Calcineurin Inhibitor Concentration by Induction of
CYP3A Activity
Anti tuberculous Rifampacin
Anticonvulsants Phenytoin Carbamazepine Oxcarbazepine (Trileptal)
Othersnafcillin, intravenous trimethoprim, intravenous sulfadimidine,
imipenem, cephalosporins, and terbinafine
Drugs that Increase Calcineurin Inhibitor Levels by Inhibition of CYP3A or
by Competition for Its Pathways
Calcium Chanersnel Block:Verapamil, diltiazem, amlodipine, and
nicardipine
Antifungal Agents Ketoconazole, fluconazole, itraconazole, voriconazole,
and
isovuconazole
Antibiotics Erythromycin Clarithromycin
Antiretroviral Ritonavir Tenofovir
Others:Amiodarone, carvedilol, allopurinol, bromocriptine, and
chloroquine
37
DRUG
INTERACTIONS
AMONG
CNIS

38. 38
• Sirolimus & CNIs Compete with each other
Blood levels of both may increase when taken together so sirolimus is given
4 hrs after CNIS
Cyclosporine inhibits enterohepatic circulation of MPA Increased doses
requirement for patients on CNI
Drugs Causing increase Nephrotoxicity of CN
NSAIDS
ACE inhibitors

39. Comparison between Antimetabolites
AZATHIOPRINE MMF
Dosage 1-2mg/kg OD 1000mg BD
Bioavailability 50% >90%
cost low-cost
immunosuppressive
High cost
immunosuppressive
Adverse Effects Myelosuppression GI upset
Hepatitis Less Myelosuppression
Infections /Malignancy Oral ulceration
39
Rationale of using MMF in Renal transplant
Improvement of graft survival and prevention of acute rejection upto 50% as
compared to AZA
No nephrotoxicity
Less Myelosuppression

40. Drug Dose Schedule Properties Monitoring
Sirolimus
1mg, 2mg
Rapamune
Single loading
dose 2-4 X
planned
maintainance
dose
6-12mg
Maintainance
dose
2-4mg
Pediatric:
loading 3mg/m2
then 1mg/m2
daily
Once daily
OB 14%
T1/2 62hrs
Trough levels 24 hr
post dose
0-6months 8-
12ng/ml
>6months 6-
10ng/ml
Everolimus
Zortres
0.25mg,0.5mg,0
.75mg
0.75mg
Pediatric: Safety
is not
established
Twice OB 20%
T1/2 28hrs
Trough levels
3-8ng/ml
40
Comparison between mTORs

41. Rationale of using mTOR inhibitors in Renal
transplant
• Conversion from CNI based to mTOR based regimen is successful in
improving renal function
• Decrease nephrotoxicity
• Decrease malignancy
• Decrease AR
• mTORs are anti proliferative and anti angigenic
• Improved graft survival
41
Limitations
Less efficacious to rejection prophylaxis
Increased Dyslipidemias
High differences of dosing
With CNIs cause increase nephrotoxicity
Impaired wound healing

42. Which protocol to use?
The Optimal Immunosuppression protocol is
unclear
Center / Patient –Adapted Protocols
42

43. Conventional Regimen
CNIs
Adjuvant agent
Corticosteroids
Antibody induction
90% to 95% graft
survival with an
acute rejection
rate of 10% to
20%.
Supplementary agents
CCB, HCRI
Infection prophylaxis
Bactrim, antifungals,
antivirals
43

44. First line
IL-2 antagonist
Basiliximab
High risk
Lymphocyte depleting
agents ATG
44

45. For Live Donor Transplant ATG
may not hav additional benefit
on graft functioning
45

46. 46

47. No induction > Basiliximab > ATG
LOW RISK
Zero HLA mismatch
Live donor
Low PRA
No DSA
Blood group compatible
Immediate graft
functioning
Short CIT
First transplant
High RISK
HLA mismatches
Young recipient ;old donor
Cadaveric donor
High PRA
Positive DSA
Blood group incompatible
Delayed graft functioning
Long CIT
Re-transplant
47

48. Initial
• Use combination of CNIs with
antimetabolite
• With or without steroids
• Monitor CNIs with trough levels
• Suggest Tacrolimus as 1st line then CIC
• Suggest MMF as 1st line antimetabolite
• Low risk patient who received induction
can be steroid free after 1st week of
transplant
• If mTOR used ,start after graft functioning
and wound healing
Long term
• Lowest planned dose in 4-6months after
Tx
• Continue CNIsintead withdrawl
Minimize acute rejection by education.
48

49. How Long to Continue Immunosuppression?
The immune system has a long memory!
• Immunosuppression is required for the functional life of the graft, even if
it has lasted two decades or more.
• Discontinuation of immunosuppressive drugs, even many years after
transplantation, may lead to late acute rejection or accelerated chronic
rejection.
49

50. What does it cost?
50

51. INFECTIONS
MALIGNANCY
UNDESIRED SIDE EFFECTS OF THE IMMUNESUPPRESENT
Weakens Immune
System
ATG
Azathioprine
Alamtuzumab
CNIs
M TOR
MMF
51

52. Whats new?
• Because of the excellent results of KT with currently available
immunosuppressants, with 1-year graft survival rates of greater than 90% in most
centers and minimal mortality, it is statistically extremely difficult to prove the
benefit of new agents or protocols in terms of patient or graft survival.
• In the pivotal trials leading to the introduction of MMF, sirolimus, and the anti-
CD25 monoclonal antibodies, the incidence of acute rejection in the patients
receiving the experimental drug protocol was compared with the incidence of
acute rejection in patients receiving standard therapy with cyclosporine,
prednisone, and azathioprine. The success of MMF in reducing the incidence of
acute rejection led to it becoming part of an updated standard therapy protocol in
many centers
52

53. Novel Drugs
• Efalizumab (Raptiva) lymphocyte-associated function-1 (LFA-1) molecule
• Janus KinKinase Inhibitors Tofacitinibase
• Bortezomib (Velcade) is a proteosomal inhibitor
• Eculizumab
Phase 2 trials were conducted on unsensitized
patients and demonstrated an equal rate of
rejection compared to a cyclosporine-based
regimen.
increased incidence of PTLD
Decrease DSA over the time
Lack data about its use
53

54. Innovative Transplantation Protocols
• Steroid Withdrawal and Steroid Avoidance
• Calcineurin Inhibitor Avoidance, Withdrawal, and Dose
Minimization.
54

55. Belatacept
• Inhibit binding of CD80 (fourfold) and CD86 (twofold) on
the antigen-presenting cell from binding with CD28, with
a 10-fold increase in T-cell inhibition.
• Results from the belatacept trials demonstrated a
significant increased incidence of post-transplant
lympho-prolipherative disease (PTLD, 1.4% in the
belatacept group vs. 0.4% in the cyclosporine group).
Progressive Multifocal Leukoencephalopathy (PML) was
also observed
• Dose 10mg/kg post operative day 1 and 5 folllowed by
2week and 4 weeks
FOLLOWED BY
• Low dose protocol Vs High dose protocol
55

56. PEDIATRIC IMMUNOSUPPRESSIVE PROTOCOLS
• The construction of the immunosuppressive protocol for pediatric transplantation is similar
to that for adults
• Many pediatric renal transplantation centers have moved toward steroid avoidance or
withdrawal.
56
ATG
Tacrolimus
MMF
Alemtezumab
Tacrolimus
MMF
Basixilimab
Prednisolone
CNI
MMF
Then
Conversion to mTOR- with low
dose CNI followed by Steroid
withdrawl

57. 57
1. Tacrolimus • Minimal or no change is made in the first 4 weeks to allow for faster tapering of
prednisone
• Dose reduction should not exceed 10% to 20%
• Tacrolimus and prednisone doses should not be lowered on the same day (risk for
precipitating an acute rejection)
• Serum creatinine and tacrolimus levels should be checked 2–3 days after each change
and before the next change is made
2. Prednisone Start tapering the dose 2–3 weeks after transplantation if stable and tacrolimus level is
within the desired range.
Initial dose tapering is by 2.5 mg each time, about 10% (may reduce by 5 mg if total dose
is >2 mg/kg). Once a 10-mg dose is reached, dose reduction is by 1 mg each time.
Longer periods of time should elapse before further tapering at the lower dose range.
Tacrolimus and prednisone doses should not be lowered on the same day.
Serum creatinine and tacrolimus levels should be checked 2–3 days after each change and
before the next change is made
3.
Mycophenolate
Mofetil
Dose reduction is only indicated if hematologic or gastrointestinal side effects develop.
Dose reduction is done in 30% to 50% increments.
It can be safely withheld for a few d or up to 3–4 weeks for severe side effects with
steroid-based regimens.
Guidelines for Drug Dose Tapering in Pediatric Renal Transplant
Recipients

58. Take Home message
• IS is permanently needed after post transplant to prevent rejection with
gradual reduction in doses with the time.
• Combined protocols usually triple regimen is used.
• Induction therapy improves short outcomes AR.
• ATG is most commonly used induction agent in our settings.
• CNIs have reduced short term graft survival but they cause nephrotoxicity
• Conversion of CNIs to m-TOR has been successful in improving renal
function with no nephrotoxicity
• Immunosuppression is not a one size fits all practice
• No Standardized immunosuppression regimen is considered effective
• Agent of choice must be determined by clinician/patient/institution
protocol.
• Infection and malignancy are general potentials untoward in addition to
drug specific side affects
• New studies require for clinically meaningful outcomes
58

59. References
• Oxford text book of Renal transplant
• Handbook of kidney transplant
• KDIGO guidelines for the recepient patients of kidney transplant
• Immunosuppressive Drugs for Kidney Transplantation; N Engl J Med 2004;351:2715-
29.
• An Update on Immunosuppressive Medications in Transplantation Dr. Lui Sing-
LeungDivision of Nephrology, University Department of Medicine, Queen Mary Hospital
and Tung Wah Hospital
• Outcome Comparison between Low-Dose Rabbit Anti-Thymocyte Globulin and
Basiliximab in Low-Risk Living Donor Kidney Transplantation J. Clin. Med. 2020, 9,
1320; doi:10.3390/jcm9051320
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