Overview

Already the disease underlying the organ dysfunction leading to transplantation listing is associated with both, an increased risk of infections and an impaired innate and adaptive immune defense. Thus, immunosuppression covers the effect of drugs administered to accommodate the life-saving allograft is added in addition to a preexisting immune dysfunction. Current protocols of immunosuppression induction and maintenance are largely tailored according to the perceived epidemiological risk (e.g. age, gender, ethnicity, parity, re-transplant) and biomarkers (e.g. DSA, HLA, AB0) of anti-donor immunity in transplant recipients. Although largely indiscriminate, current immunosuppressive drugs differ in their respective mechanism of action. This provides an opportunity for intelligent combination to reduce direct toxicity as well as infectious complications. However, as is the case for different levels of anti-donor immunity, transplant recipients also differ in their individual quantity and quality of antimicrobial adaptive immunity, and the different effectors strengths does not necessarily overlap. Of note, there is evidence that some immunosuppressive drugs selective spare and target relevant functions. The assessment of antimicrobial immunity using interferon-gamma release assays is showing promise for some infectious agents. For cytomegalovirus, Epstein-Barr virus; and BK polyomavirus, the course and dynamics of the blood viral loads have been harnessed as a net resultant marker of progression and control.  

Objectives

1- Review immune dysfunction, immunodeficiency, and specific immunosuppressive drugs pre- and post-transplant.

2- Consult on immunosuppressive drugs, specific infections and risk of disease.

3- Juxtapose BK polyomavirus and cytomegalovirus regarding managing transplant patients through immunosuppression, and point out limitations for Epstein-Barr virus, and other infectious agents.