Developments and dilemmas in renal transplantation.
The number of patients waiting for a kidney transplant is about three times greater than the number of transplants performed each year. This article highlights current immunosuppression protocols and the newer immunosuppressive drugs under investigation in a number of multicenter trials. These hold out the promise of reducing the frequency of acute rejection and of prolonging graft survival. They are divided into three groups. The first, like cyclosporine, interferes with the action of interleukin 2. The second, like azathioprine, are antimetabolites; and the third, new monoclonal antibodies. The use of antibody-induction therapy is compared with standard regimens. There are risks related to prednisone withdrawal protocols and inadequate cyclosporine dosing that may lead to accelerated graft loss. Cardiovascular disease is a significant problem in older diabetic patients for whom coronary angiography is recommended. A defined set of risk factors is outlined that predicts which younger diabetic patients should have a cardiovascular evaluation. Chronic liver disease is a growing problem and rational strategies are emerging from studies of patients with biopsy-proven active hepatitis. The presence of hepatic inflammation is associated with progressive liver disease and patients must be made aware of this risk when seeking transplantation. A large number of studies of various prophylactic regimens are starting to provide data on the cost-effective reduction of cytomegalovirus disease in transplant recipients. It is recommended that patients receiving antibody therapy also receive preemptive gangciclovir. The issue of chronic allograft rejection is discussed briefly. The most important predictors of chronic allograft rejection are the frequency of acute rejection, inadequate immunosuppression, and infections.(ABSTRACT TRUNCATED AT 250 WORDS)
Wilkinson
A H
AH
Department of Medicine, UCLA School of Medicine, USA.
Rosenthal
J T
JT
Danovitch
G M
GM
D004359:Drug Therapy, Combination; D006084:Graft Rejection / Q000150:complications / Q000517:prevention & control*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007376:Interleukin-2 / Q000037:antagonists & inhibitors / Q000378:metabolism; D016030:Kidney Transplantation / Q000276:immunology*; D011183:Postoperative Complications / Q000628:therapy*; D051437:Renal Insufficiency / Q000378:metabolism / Q000601:surgery; D016896:Treatment Outcome
D007166:Immunosuppressive Agents; D007376:Interleukin-2