Complications of

Immunosuppression

RACS Lecture
Lachlan Maddock
Immunosuppression History
• 1950s
• Total Body Irradiation
• 1960s
• Steroids, Azathioprine
• 1970s
• Antilymphocyte globulin
• 1980s
• Cyclosporin
• 1990s
• Tacrolimus, Sirolimus,
Mycophenolate
 Drug Treatment Overview
• Non-Specific Anti-Proliferative
• Total body irradiation, Azathioprine, Methotrexate,
Cyclophosphamide

• Lymphocyte Depletion
• Prednisolone, Anti-lymphocyte globulin, Monoclonal
antibodies

• Lymphocyte Inactivation
• Cyclosporine, Tacrolimus, Sirolimus, Mycophenolate
 Complications
• Drug-Specific Complications

• General Complications
• Infection
• Cancer
• Cardiovascular Disease
 Infection
• Viral
• CMV
• Common, Potentially serious
• Herpes
• Simplex, Zoster
• Hepatitis B

• Bacterial
• Wound infections post op
• UTI
• Pneumonia

• Fungal
• Candida
• Aspergillosis

• Protozoal
• Pneumocystis carinii
Harrisons Online 2008
Sabiston Textbook Surgery 2007
 Infection - Prophylaxis
• Pre-Operative
• Vaccines

• Post Operative
• Prophylactic treatment
• Antivirals
• Antifungals
• Antibiotics
 Cancer

• Overall Incidence of tumours

approximately 100 times that of age
matched general population

Harrisons Online 2008

Cumulative Risk of Malignancy
after Transplantation
100

80

60
Any
Skin
Non skin
40
Gen. Pop

20

0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
Years after transplantation
ANZDATA 2003
Relative Risk of Post-transplant Malignancy

Skin = 200 Kaposi’s Sarcoma = 26.4 Lymphoma = 10.2

Melanoma = 3.2 Thyroid = 4.5 Colorectal = 1.9

Breast = 1.3 Kidney, ureter, bladder Stomach = 1.24

& urethra = 6.7
 Cardiovascular Risk
• Significant Morbidity & Mortality
• Highest causes of death after 1st year post
transplant are chronic rejection and cardiovascular
death
• Multifactorial
• Hypertension
• Hypercholesterolaemia
• Chronic rejection
• Drugs
• CMV infection
CVS Disease Prevention
• Antihypertensives
• ACE

• Lipid lowering
• Diet, Statins

• Surveillance
 References
• Sabiston Textbook of Surgery 18th
Edition 2007
• Oxford Textbook of Surgery 2nd Edition
2000
• Harrison’s Principles of Internal
Medicine 2008 Online