Given that long-term graft survival requires ongoing immunosuppression, maximizing outcomes means minimizing complications of immunosuppressive therapies. Early after transplantation, when immunosuppression is most intense, risk of infectious complications is greatest.116 In 1999, these infections are primarily viral, with bacterial and fungal infections posing life-threatening risk in only a limited number of patients. For long-term survivors, risk of infection diminishes with time, at least partially due to reduction in immunosuppressant drug dosages. However, risk of malignancy, itself often viral related, increases and remains substantially greater in transplant recipients than in the general population.117 In addition, there are specific adverse effects of each immunosuppressive agent that require surveillance, such as cyclosporine nephrotoxicity and hypertension, steroid-induced bone disease, or hyperlipidemia.118–120
A common aphorism is that successful transplantation is not a cure, but rather substitutes the manageable disease of immunosuppression for the incurable and fatal disease of organ failure. Current clinical practice, with substantial scientific underpinnings, requires continual provision of adequate immunosuppression to ensure optimal outcomes for recipients. While future developments may change this paradigm, long-term survival of both graft and patient mandates ongoing access not only to a full complement of immunosuppressive agents, but also to requisite clinical expertise.
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