- Email: [email protected]
Outcomes post renal transplant: Immunosuppression Strategies
Indian J Transplant 2008; 2: 1-2
1
Editorial
Outcomes post renal transplant: Immunosuppression Strategies RK Sharma Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
A
dvancement of transplantation practices and immunosuppressive management in recent years has resulted in improvement in short term outcomes in renal transplant recipients. Increased patient and graft survival mean that patients are living long and we need to focus on both short term care and chronic management in order to improve long term outcomes. Acute rejection rates have declined markedly over the last decade in renal transplant recipients. Much of this advancement is result of introduction of innovative immunosuppression protocols including cyclosporine, tacrolimus and mycophenolate mofetil. The decrease in acute rejection rates has also been driven by the greater utilization of antibody induction. Despite the advances in immunosuppression, long term graft survival has not improved in a commensurate manner. There is also increasing number of transplantation carried out in high risk recipients, utilizing more extended criteria donors. Amongst the living donor renal transplantation elderly and marginal donors add to the complexities of immunosuppression management strategies which may need to be tailored to the needs of an individual recipient. In terms of the allograft loss perse, Address for correspondance: Prof RK Sharma Department of Nephrology Sanjay Gandhi Post Graduate Institute of Medical Sciences Rae Bareli Road, Lucknow 226014 Email: [email protected]
it is possible that much of the graft attrition can be ascribed to the inability of current immunosuppression regimens to adequately control anti HLA response or persisting low grade inflammatory responses against the transplanted organ. In an attempt to limit long term toxicity and reduce cardiovascular side effects and mortality, both steroid minimization, and calcineurin inhibitor minimization/avoidance regimens have been studied. These immunosuppression protocols seem to have benefits, but long term results are still not clear and one would need to see if these innovative protocols would stand the test of time. The recent ‘Efficacy Limiting Toxicity Elimination, ELiTE’ – SYMPHONY trial has indicated that at least for now, a regimen of low dose tacrolimus with mycophenolic acid compound along with steroids provides the best balance of efficacy and avoidance of severe toxicity of immunosuppressive drugs. The latest Opelz’s Collaborative Transplant Study (CTS) Registry report – indicates that best long term outcome results are achieved still in CsA based immunosuppression regimens. While considering long term outcomes in renal transplant patients, we should identify factors over which we can exercise some degree of control, like delayed graft function, calcineurin inhibitor toxicity, suboptimal immunosuppression and non adherence, factors which lead to chronic allograft nephropathy (CAN). Cardiovascular disease risk factors like hypertension, hyperlipidemia and diabetes after transplantation should be controlled. These modifiable factors would need to be Copyright © 2008 by The Indian Society of Organ Transplantation
2
Indian Journal of Transplantation
addressed by choosing immunosuppression strategy with least toxicity and excellent control of rejection rates. It may be prudent to optimize the immunosuppression regimen of renal transplant recipients on an individual basis. A new prolonged release formulation of tacrolimus may be of value when considering ways to improve long term graft protection, as it may provide same efficacy as conventional tacrolimus (requiring twice/day dosing) with added benefits associated with a once daily dosing schedule which may improve compliance and adherence
Indian J Transplant 2008; 2: 1-2
by allowing simplification of the immunosuppression regimen. The present issue carries a consensus meeting statement which is result of issues addressed by the Indian Transplant physicians and surgeons about immunosuppressive regimens suitable for renal transplant recipients. We need to continue efforts to improve both short and long term outcomes of renal allograft by optimizing immunosuppression. This would need limiting the toxicity while achieving the best graft survival and outcome both on long and short term basis.
W
e would like to invite research publications (both basic and clinical) in areas of transplantation. The ‘Editorial Board’ of Indian Journal of Transplantation would like this journal to become a platform for publications of research work and evidence based reports of high scientific value in area of organ transplantation. I would like to take this opportunity to solicit inputs and participation by all members of Indian Society of Organ Transplantation, so that Indian Journal of Transplantation becomes an important focus for projecting the experience in transplantation by clinicians and researchers, not only from Indian subcontinent but also from South East Asian region as a whole for addressing issues and problems unique and relevant to various areas of transplantation. RK Sharma, Editor S Guleria, Joint Editor
Copyright © 2008 by The Indian Society of Organ Transplantation
1
Editorial
Outcomes post renal transplant: Immunosuppression Strategies RK Sharma Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
A
dvancement of transplantation practices and immunosuppressive management in recent years has resulted in improvement in short term outcomes in renal transplant recipients. Increased patient and graft survival mean that patients are living long and we need to focus on both short term care and chronic management in order to improve long term outcomes. Acute rejection rates have declined markedly over the last decade in renal transplant recipients. Much of this advancement is result of introduction of innovative immunosuppression protocols including cyclosporine, tacrolimus and mycophenolate mofetil. The decrease in acute rejection rates has also been driven by the greater utilization of antibody induction. Despite the advances in immunosuppression, long term graft survival has not improved in a commensurate manner. There is also increasing number of transplantation carried out in high risk recipients, utilizing more extended criteria donors. Amongst the living donor renal transplantation elderly and marginal donors add to the complexities of immunosuppression management strategies which may need to be tailored to the needs of an individual recipient. In terms of the allograft loss perse, Address for correspondance: Prof RK Sharma Department of Nephrology Sanjay Gandhi Post Graduate Institute of Medical Sciences Rae Bareli Road, Lucknow 226014 Email: [email protected]
it is possible that much of the graft attrition can be ascribed to the inability of current immunosuppression regimens to adequately control anti HLA response or persisting low grade inflammatory responses against the transplanted organ. In an attempt to limit long term toxicity and reduce cardiovascular side effects and mortality, both steroid minimization, and calcineurin inhibitor minimization/avoidance regimens have been studied. These immunosuppression protocols seem to have benefits, but long term results are still not clear and one would need to see if these innovative protocols would stand the test of time. The recent ‘Efficacy Limiting Toxicity Elimination, ELiTE’ – SYMPHONY trial has indicated that at least for now, a regimen of low dose tacrolimus with mycophenolic acid compound along with steroids provides the best balance of efficacy and avoidance of severe toxicity of immunosuppressive drugs. The latest Opelz’s Collaborative Transplant Study (CTS) Registry report – indicates that best long term outcome results are achieved still in CsA based immunosuppression regimens. While considering long term outcomes in renal transplant patients, we should identify factors over which we can exercise some degree of control, like delayed graft function, calcineurin inhibitor toxicity, suboptimal immunosuppression and non adherence, factors which lead to chronic allograft nephropathy (CAN). Cardiovascular disease risk factors like hypertension, hyperlipidemia and diabetes after transplantation should be controlled. These modifiable factors would need to be Copyright © 2008 by The Indian Society of Organ Transplantation
2
Indian Journal of Transplantation
addressed by choosing immunosuppression strategy with least toxicity and excellent control of rejection rates. It may be prudent to optimize the immunosuppression regimen of renal transplant recipients on an individual basis. A new prolonged release formulation of tacrolimus may be of value when considering ways to improve long term graft protection, as it may provide same efficacy as conventional tacrolimus (requiring twice/day dosing) with added benefits associated with a once daily dosing schedule which may improve compliance and adherence
Indian J Transplant 2008; 2: 1-2
by allowing simplification of the immunosuppression regimen. The present issue carries a consensus meeting statement which is result of issues addressed by the Indian Transplant physicians and surgeons about immunosuppressive regimens suitable for renal transplant recipients. We need to continue efforts to improve both short and long term outcomes of renal allograft by optimizing immunosuppression. This would need limiting the toxicity while achieving the best graft survival and outcome both on long and short term basis.
W
e would like to invite research publications (both basic and clinical) in areas of transplantation. The ‘Editorial Board’ of Indian Journal of Transplantation would like this journal to become a platform for publications of research work and evidence based reports of high scientific value in area of organ transplantation. I would like to take this opportunity to solicit inputs and participation by all members of Indian Society of Organ Transplantation, so that Indian Journal of Transplantation becomes an important focus for projecting the experience in transplantation by clinicians and researchers, not only from Indian subcontinent but also from South East Asian region as a whole for addressing issues and problems unique and relevant to various areas of transplantation. RK Sharma, Editor S Guleria, Joint Editor
Copyright © 2008 by The Indian Society of Organ Transplantation