Editorial
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Sep 24, 2015; 5(3): 73-80
Published online Sep 24, 2015. doi: 10.5500/wjt.v5.i3.73
Minimization vs tailoring: Where do we stand with personalized immunosuppression during renal transplantation in 2015?
Lajos Zsom, László Wagner, Tibor Fülöp
Lajos Zsom, Division of Transplantation, Institute of Surgery, University of Debrecen, 4032 Debrecen, Hungary
László Wagner, Department of Transplantation and Surgery, Semmelweis University, 1085 Budapest, Hungary
Tibor Fülöp, Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216-4505, United States
Author contributions: Zsom L was first author, conceptual design, initial draft, literature review, finalizing manuscript; Wagner L contributed to clinical correlation, literature review, critical review of the manuscript; Fülöp T contributed to literature review, manuscript development and coordinating manuscript revisions, corresponding author.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Tibor Fülöp, MD, Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, L 504, Jackson, MS 39216-4505, United States. tiborfulop.nephro@gmail.com
Telephone: +1-601-9845670 Fax: +1-601-9845765
Received: January 29, 2015
Peer-review started: January 30, 2015
First decision: May 14, 2015
Revised: June 13, 2015
Accepted: July 11, 2015
Article in press: July 14, 2015
Published online: September 24, 2015
Processing time: 238 Days and 7.4 Hours
Abstract

The introduction of novel immunosuppressive agents over the last two decades and the improvement of our diagnostic tools for early detection of antibody-mediated injury offer us an opportunity, if not a mandate, to better match the immunosuppression needs of the individual patients with side effects of the therapy. However, immunosuppressive regimens in the majority of programs remain mostly protocol-driven, with relatively little inter-program heterogeneity in certain areas of the world. Emerging data showing different outcomes with a particular immunosuppressive strategy in populations with varying immunological risks underscore a real potential for “personalized medicine” in renal transplantation. Studies demonstrating marked differences in the adverse-effect profiles of individual drugs including the risk for viral infections, malignancy and renal toxicity call for a paradigm shift away from a “one size fits all” approach to an individually tailored immunosuppressive therapy for renal transplant recipients, assisted by both screening for predictors of graft loss and paying close attention to dose or class-related adverse effects. Our paper explores some of the opportunities during the care of these patients. Potential areas of improvements may include: (1) a thorough assessment of immunological and metabolic risk profile of each renal transplant recipient; (2) screening for predictors of graft loss and early signs of antibody-mediated rejection with donor-specific antibodies, protocol biopsies and proteinuria (including close follow up of adverse effects with dose adjustments or conversions as necessary); and (3) increased awareness of the possible link between poor tolerance of a given drug at a given dose and non-adherence with the prescribed regimen. Altogether, these considerations may enable the most effective use of the drugs we already have.

Keywords: Glucocorticoids; Donor-specific antibodies; Kidney transplantation; Mechanistic (mammalian) target of rapamycin inhibitor; Mycophenolate mofetil; Non-adherence; Calcineurin inhibitor; Sirolimus

Core tip: When managing individual transplant recipients, awareness of potential treatment-induced complications and pre-existing comorbidities may take precedence over excessively rigid adherence to pre-existing pathways. Potential areas of improvement are: (1) a thorough assessment of immunological and metabolic risk profile of each donor recipient; (2) screening for predictors of graft loss and early signs of antibody-mediated rejection with donor-specific antibodies, protocol biopsies and proteinuria (including close follow up of adverse effects with dose adjustments or conversions as necessary); and (3) increased awareness of the possible link between poor tolerance of a given drug at a given dose and non-adherence with the prescribed regimen.