IMMUNOSUPPRESSIVE THERAPY AS A DETERMINANT OF TRANSPLANTATION OUTCOMES

Although surgical proficiency is essential to the immediate outcome of transplantation, long-term success depends upon how adequately the tr ansplantation recipient is managed. Immunosuppression, the most critic al aspect of after care, is subject to wide variation. In January 1990 , a survey was sent to the directors of all transplant programs in the United States performing one or more kidney, heart, liver, heart-lung , or pancreas transplant in 1988. Detailed data were obtained on both the drugs and methods used for induction and maintenance immunosuppres sion, as well as the treatment of rejection. Each program director was asked to rank each immunosuppressive approach according to its percei ved impact on patient outcomes. Over 85% of all eligible program direc tors completed the survey. There is no evidence of survey respondent b ias. The use of polyclonal and monoclonal agents for induction immunos uppression was favored most by pancreas program directors (72-76%). Th ese agents were least preferred by liver transplant programs (35-37%). About half of kidney, heart, and heart-lung program directors preferr ed these agents. Triple-drug therapy consisting of CsA, PRED, and AZA was considered the most preferable maintenance protocol for all transp lants (i.e., kidney, 89%; heart, 94%; liver, 88%; heart-lung, 86%; pan creas, 96%). Either i.v. steroids or OKT3 were regarded as the preferr ed approaches for the treatment of acute or resistant rejection. Final ly, the acceptability of outpatient treatment of rejection varied by t ransplant type (i.e., kidney, 9%; heart, 58%; liver, 5%; heart-lung, 2 9%; pancreas, 8%). Although there are similarities in the ratings of v arious aspects of immunosuppressive therapy, there are important diffe rences. This information is critical to anticipate the implications of new immunosuppressive agents and to evaluate changes in the use of ex isting drugs and therapeutic approaches.