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Optimizing immunosuppression: who can do more with less?

Clinical kidney transplantation has taken a remarkable journey over the last 60 years from concept, to high-risk endeavor for the few, to now a controlled and predictable activity [1,2]. Most of the risk has been taken by patients, many of them desperate, who are the heroes of this progression from a rare event to a common practice around the world. By example, small steps in surgical technique, histocompatibility testing, deceased donor organ recovery and preservation, living donor evaluation and safety, infectious disease isolation and treatment, diagnosing and treating allograft rejection, and the medical management of patients with renal failure both before and after transplant have been incrementally introduced to optimize the outcomes and promote patient safety. However, while we generally understand the role of both acute and chronic rejection in the fate of solid-organ transplants, we remain tentative regarding the use of immunosuppression to control the consequences of the alloimmune response. Although the state of drug-free tolerance may be the ultimate goal for patient care, contemporary clinical transplant practice remains a balance between not enough and too much immunosuppression. Not enough results in rejection, progressive graft injury, and perhaps recurrent disease; too much results in patient injury, primarily infection, and cancer (Fig. 1). The 10-year randomized trial from Thierry et al. [3] in this issue of Transplant International