Minimization protocols in pancreas transplantation

Diagnosis of immunologic injury (acute and chronic) is much more difficult in pancreas transplants when compared with transplants of other organs. Currently, the immunosuppressive regimen for induction involves calcineurin inhibitors (CNI), antimetabolites and corticosteroids (Cs). This strong and nonspecific regimen does not take into consideration pancreas specificities (i.e. the need to avoid diabetogenic compounds). For obvious reasons, CNI might be calling for review, if permanently indicated in recipients of solitary pancreas with mild renal dysfunction. CNI as well as corticosteroids may induce hyperglycemia and contribute to differential diagnosis of a rejection process. However, in spite of the benefits accruing from withdrawal of above immunosuppressive agents, minimization or avoidance of these drugs could be dangerous and may end up with graft loss (i.e. antibody-mediated process). Long-term results of pancreas transplantation are now achieving comparable survival rates similar to the transplant of traditional organs such as kidney and liver. As a consequence, the physicians’ objectives are to prolong the patient’s quality of life and organ function as long as possible. Weaning strategies in regard to CNI and steroids are tested. Sirolimus, everolimus, CTLA-4 Ig, etc, are agents known to be either both nonnephrotoxic and nondiabetogenic or less so when compared with CNI. Their impact on pancreas transplantation is beginning to be evaluated. Large randomized trials in all pancreas categories, with long-term clinical and histologic results, are mandatory to establish new guidelines for immunosuppressive regimens for pancreas transplantation

Immunosuppression minimization in kidney transplantation

Kidney transplantation is considered the best treatment for patients with end-stage renal failure, even in extreme age-groups. Immunosuppression for “life” is, however, mandatory. This chronic, somewhat unselected, inhibition of the host immune system may induce complications, such as cancer and infection, that could counterbalance the benefits achieved by the transplant. In addition, all currently used immunosuppressors have several side-effects, impeding their long-term use. Consequently, drug associations are frequently tested by different centres according to their own practices, resulting in different survival and tolerance profiles. Corticosteroids and calcineurin inhibitors are the cornerstones of current immunosuppressive regimens. However, they are also the main culprits of adverse-events and side-effects encountered after transplantation. Lowering the doses of each drug, or even eliminating them from the immunosuppressive menu, has been evaluated by many groups over the last two decades. This review summarises a huge number of studies dealing with corticosteroid and calcineurin inhibitor minimization, including withdrawal and avoidance trials. It is hard today to propose any practical guidelines on such a controversial topic. Good results are achieved by some groups and bad results by others. The lack of long-term follow-up in randomized studies contributes to this debate. Nevertheless, it seems possible and safe to avoid corticosteroids and/or calcineurin inhibitors in many patients. The application of protocol biopsies as well as new immunological tests to determine the degree of immunosuppression will certainly help transplant physicians to provide more personalized treatment strategies

First global forum on education on organ donation and transplantation for schools.

The Transplantation Society, in collaboration with the Canadian Society of Transplantation, organized a forum on education on ODT for schools. The forum included participants from around the world, school boards, and representatives from different religions. Participants presented on their countries' experience in the area of education on ODT. Working groups discussed about technologies for education, principles for sharing of resources globally, and relationships between education, and health authorities and non-governmental organizations. The forum concluded with a discussion about how to best help existing programs and those wishing to start educational programs on ODT