. "Appendix D: Immunosuppressive Therapy: The Scientific Basis and Clinical Practice of Immunosuppressive Therapy in the Management of Transplant Recipients." Extending Medicare Coverage for Preventive and Other Services. Washington, DC: The National Academies Press, 2000.
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Extending Medicare Coverage for Preventive and Other Services
Avoiding Excessive Immunosuppression
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
SUMMARY AND CONCLUSION
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.
2. Rennie D: Home dialysis and the costs of uremia. N Engl J Med 298:399–400, 1978.
3. Friedman EA, Kountz SL: Impact of HR-1 on the therapy of end-stage uremia: How and where should uremia be treated? N Engl J Med 288:1286–1288, 1973.
4. Murray JE, Merrill JP, Harrison JH, Wilson RE, Dammin GJ: Prolonged survival of human-kidney homografts by immunosuppressive drug therapy. N Engl J Med 268: 1315–1323, 1963.
5. United States Renal Data System: Excerpts from USRDS 1998 Annual Data Report. Am J Kidney Dis 32(Suppl 1):S1–S162, 1998.
6. UNOS (United Network for Organ Sharing): 1997 Annual Report of the U.S. Scientific Registry for Transplant Recipients in the Organ Procurement and Transplantation Network: DHHS/HRSA, Richmond, Virginia, UNOS, 1997.
7. Gaston RS, Deierhoi MH, Hudson SL, Kew CE, Curtis JJ, Julian BA, Young CJ, Gallichio MJ, Diethelm AG: Sequential immunoprophylaxis in renal transplantation: Comparison of two doses of daclizumab to OKT3 induction (abstract). J Am Soc Nephrol 10 (in press), 1999.