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What You Should Know About Immunosuppressive Drugs

Why are they important?
The first successful kidney transplant surgery in the United States took place in 1954. However, the procedure did not immediately become widespread. This was because the immune system of the kidney transplant recipient would recognize the transplanted kidney as foreign and attack it. This process is called rejection. It causes strong inflammation within the transplanted kidney, which can stop working completely if unchecked. Rejection almost always occurs without specific anti-rejection therapy. Successful transplantation procedures only became commonplace when immunosuppressive drugs were developed to combat rejection.

The immune system is that part of your body that responds to foreign things. This includes everyday things such as viruses and bacteria, but also includes transplanted organs. The immune system is also the target of immunosuppressive drugs. These drugs change your body’s response to foreign things, including your transplanted kidney. They make it possible to have a working transplant kidney that may last for years and sometimes even decades.

How do I take them?
Scientists have created many classes of immunosuppressive drugs. They fall under two main categories:
1. Traditional drugs: These come in the usual pill and capsule forms. They are usually taken by mouth. Sometimes for people in the hospital, they also exist in intravenous (IV) forms. These medications all interact with the immune system in unique ways. Usually a patient is on a combination of two of these medications, sometimes with prednisone as a third. Common examples include:

  • prednisone (“steroids”)
  • cyclosporine (®Sandimmune, Neoral, Cicloral, Gengraf, Deximune)
  • tacrolimus (®Prograf, Advagraf, Astragraf)
  • mycophenolic acid (®CellCept, Myfortic)
  • azathioprine (®Imuran)
  • sirolimus (®Rapamune).

2. Biologicals: These are proteins that change the body’s immune response by interacting with specific pathways of the immune system. They are given by IV, either in the hospital or in outpatient centers. They can be given right before, during, or after the transplant surgery. They can also be used to treat rejection episodes. Rarely, they are given on a long-term basis instead of oral traditional drugs. Examples include:

  • anti-thymocyte globulins (ATGs)
  • basiliximab (®Simulect)
  • daclizumab (®Zenapax)
  • intravenous immunoglobulins (IVIG)
  • belatacept (®Nulojix)
  • rituximab (®Rituxan).

Most transplant centers use a combination of these drugs. You will most likely take more than one immunosuppressive drug at a time. You will also need frequent blood work to monitor how your kidney is working on the medication combination. Additionally, some of the drugs need to be checked in the blood to be sure that their level is in the right
range. If the drug level is too low, your immune system is not getting the right amount of treatment to stop rejection. If the drug level is too high, you may be getting too much of the drug and therefore open up yourself to side effects of being over-immunosuppressed. It is very important to follow up with your transplant doctors as scheduled and to take these drugs exactly as you’ve been told.

What side effects are there?
Immunosuppressive drugs lower the overall strength of your immune system. In doing so they reduce your body’s ability to fight off potential bacterial, viral and other infections. We recommend that you stay up-to-date on all your vaccinations as directed by your transplant doctors. We also recommend that you tell your doctors and transplant team when you feel you may be developing an infection. Common symptoms of infection include fever, cough with phlegm, or pain and burning while urinating.

Your immune system also helps to fight off cancer. Taking immunosuppressive drugs therefore may make it more likely for you to develop certain kinds of cancer. The risk is small, and most patients do not develop cancer after kidney transplant. We do recommend that you undergo routine cancer screening as appropriate for your age and gender. The most common cancer after transplant is skin cancer (squamous and basal cell cancer). These are usually easily treatable. Avoiding the sun and using sunscreen may help prevent the development of skin cancer.

Other side effects differ depending on the exact combination of medications that you take. These may include diabetes, or worsening of pre-existing diabetes, high cholesterol, high blood pressure, weight gain, headaches, tremors, and diarrhea. Just because a side effect is listed does not mean you will get it: everyone has a unique response to these medications. The transplant doctors will help you select a medication or combination of medications that best suits you.