title: Changing Paradigms in the Management of Rejection in Kidney Transplantation: Evolving From Protocol-Based Care to the Era of P4 Medicine.
abstract: OBJECTIVE
  P4 medicine denotes an evolving field of medicine encompassing predictive, preventive, personalized, and participatory medicine. Using the example of kidney allograft rejection because of donor-recipient incompatibility in human leukocyte antigens, this review outlines P4 medicine's relevance to the various stages of the kidney transplant cycle.
  
  
  METHODS
  A search for English articles was conducted in Medline via OvidSP (up to August 18, 2016) using a combination of subject headings (MeSH) and free text in titles, abstracts, and author keywords for the concepts kidney transplantation and P4 medicine. The electronic database search was expanded further on particular subject headings.
  
  
  RESULTS
  Available histocompatibility methods exemplify current applications of the predictive and preventive domains of P4 medicine in kidney transplant recipients' care. Pharmacogenomics are discussed as means to facilitate personalized immunosuppression regimens and promotion of active patient participation as a means to improve adherence.
  
  
  CONCLUSIONS
  For simplicity, this review focuses on rejection. P4 medicine, however, should more broadly address health concerns in kidney transplant recipients, including competing outcomes such as infections, malignancies, and cardiovascular disease. This review highlights how biomarkers to evaluate these competing outcomes warrant validation and standardization prior to their incorporation into clinical practice.
  
  
  CONCLUSIONS
  Consideration of all 4 domains of the P4 medicine framework when caring for and/or studying kidney transplant recipients has the potential of increasing therapeutic efficiency, minimizing adverse effects, decreasing health care costs, and maximizing wellness. Technologies to gauge immune competency, immunosuppression requirements, and early/reversible immune-mediated injuries are required to optimize kidney transplant care.
authors.affiliation: Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Mirela
authors.initials: M
authors.lastname: Maier
authors.affiliation: Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Tomoko
authors.initials: T
authors.lastname: Takano
authors.affiliation: Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada; Multi-Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Ruth
authors.initials: R
authors.lastname: Sapir-Pichhadze
keywords: adherence; biomarkers; immune competency; pharmacogenomics; surveillance