Current concepts of immunosuppression and side effects

The first successful human solid organ transplant was a renal transplant between two identical twin siblings, on 23 Dec 1954 [103]. Given the monozygosity, essentially no immunosuppression was used. The recipient never had a rejection episode but died 8 years later from recurrent glomerulonephritis. The introduction of immunosuppression with prednisone, azathioprine, and occasionally antilymphocyte globulin (ALG) in the 1960s allowed successful nonidentical living donor and deceased donor transplants. Through the 1970s and early 1980s, 1-year survival rates and acute rejection rates were around 60%. In the mid-1980s, cyclosporine was introduced and rejection rates decreased to 40-50% and 1-year survival rates increased to 75-85%. In the last 2 decades with the introduction of newer immunosuppressive induction agents such as basiliximab, daclizumab, and thymoglobulin and maintenance agents including tacrolimus, mycophenolate, and sirolimus, transplant patients are able to achieve 1 year graft survival rates in excess of 90% and acute rejection rates of 5-20%. Over the last several years, the focus of even newer immunosuppressive drugs regimens has included immunosuppression targeting the co-stimulatory pathways and avoiding toxicities associated with steroids and the calcineurin inhibitors cyclosporine and tacrolimus.