Future trends in organ transplant recipients--important issues for dermatologists

It is on the tip of everyone's tongue in the transplant community that recent improvements in short-term survival of solid organ allografts have not translated into the expected increase in long-term survival. Besides chronic immune-mediated damage to the transplanted organ, the poor long-term survival of allografts has been attributed to the nephrotoxic effects of the calcineurin inhibitors. Moreover, the immunosuppressive burden and metabolic side effects of the current anti-rejection drugs are clearly related to increased rates of malignancies, infections and accelerated atherosclerosis, all of which make up for the premature death of a considerable proportion of transplant recipients with a functioning allograft. Therefore, attempts have been made over the last decade to either reduce or withdraw both steroids and calcineurin inhibitors from maintenance regimens. Furthermore, there is an ongoing intensive search for new less toxic and more specific drugs which would ideally selectively impair the alloimmune response while preserving the immune system's capacity to fight infection and malignancy (i.e. induce tolerance). Moreover, new concepts have emerged to individualize a patient's immunosuppressive therapy based on an improved pretransplant risk assessment. With the causes of chronic allograft damage being increasingly well defined, better and more personalized long-term follow-up strategies are being developed to ultimately prevent late allograft loss. These aspects will be reviewed here with a focus on kidney transplantation and the possible impact of these new approaches on the incidence of skin cancer.