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Prevention of complications from use of conventional immunosuppressants: a critical review

Abstract

Synthetic immunosuppressive drugs are largely used in immune-related renal diseases and in kidney transplantation. Most of these drugs have a low therapeutic index (the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective), which means that the drug should be dosed carefully and the patient monitored frequently. In this review, we consider the categories of synthetic immunosuppressive agents more frequently and conventionally used in clinical nephrology: glucocorticoids, Aalkylating agents (cyclophosphamide, chlorambucil), purine synthesis inhibitors (azathioprine, mycophenolate salts) and calcineurin inhibitors (cyclosporine, tacrolimus). For each category the possible side effects will be reviewed, the general and specific measures to prevent or treat the adverse events will be suggested, and the more common mistakes that may increase the risk of toxicity will be described. However, the efficacy and safety of immunosuppressive agents depend not only on the pharmacologic characteristics of single drugs but can be influenced also by the clinical condition and genetic characteristics of the patient, by the typology and severity of the underlying disease and by the interaction with other concomitantly used drugs.

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Correspondence to Claudio Ponticelli.

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Dr Ponticelli has no conflict of interest to disclose. Dr. Glassock is a compensated consultant to Bristol-Myers Squibb, Genentech, Chemocentryx, Mallinckrodt, Apellis, Ionis, Achillion, Omeros. He also receives a stipend from Wolters -Kluwer (UpToDate) and Karger Publications (American Journal of Nephrology and Nephrology Viewpoints) for Editorial Services. He owns stock in REATA, Inc. (Bardoxolone).

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Ponticelli, C., Glassock, R.J. Prevention of complications from use of conventional immunosuppressants: a critical review. J Nephrol 32, 851–870 (2019). https://doi.org/10.1007/s40620-019-00602-5

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Keywords

  • Glucocorticoids
  • Calcineurin inhibitors
  • Cyclophosphamide
  • Mycophenolic acid
  • Immunosuppression