HMG-CoA reductase inhibitors as immunomodulators: potential use in transplant rejection

Statin therapy for preventing cardiovascular diseases in patients treated with tacrolimus after kidney transplantation

Background

Lipid abnormalities are prevalent in tacrolimus-treated patients. The aim of the study was to evaluate the preventive effects of statin therapy on major adverse cardiovascular events (MACE) in patients treated with tacrolimus-based immunosuppression after kidney transplantation (KT), and to identify the risk factors.

Methods

This observational cohort study included adult patients who underwent KT and were treated with tacrolimus. Patients who received any lipid-lowering agents except statins, or had a history of immunosuppressant use before transplantation were excluded. The primary outcome was the adjusted risk of the first occurrence of MACE. The secondary outcomes included the risk of individual cardiovascular disease (CVD) and changes in cholesterol level. Subgroup analyses were performed in the statin-user group according to the dosage and/or type of statin.

Results

Compared with the control group (n=73), the statin-users (n=92) had a significantly reduced risk of MACE (adjusted HR, 0.31; 95% CI, 0.13–0.74). In the Cox regression analysis, old age, history of CVD, and comorbid hypertension were identified as independent factors associated with increased MACE. The total cholesterol levels were not significantly different between the two groups. Subjects with higher cumulative defined daily dose of statins had significantly lower risks of MACE.

Conclusion

Statin therapy in patients treated with tacrolimus after KT significantly lowered the risk of MACE. Long-term statin therapy is clearly indicated in older kidney transplant recipients for secondary prevention.

Heat Shock Protein Antibody Titers Are Reduced by Statin Therapy in Dyslipidemic Subjects: A Pilot Study

Antibody titers to heat shock protein (Hsp)-60 and -65 are positively related to risk of vascular disease and cardiovascular endpoints. There are few data on the factors that regulate the levels of these antibodies. It is known that the statins have antiinflammatory and immunoregulatory properties. The authors examined the effects of 2 statins, simvastatin (Zocor®) and atorvastatin (Lipitor®) on antibody titers to Hsp-60, -65, and -70 in a group of dyslipidemic patients. Twenty patients attending a lipid clinic, and previously not receiving lipid-lowering treatment, were treated with 10 mg of simvastatin (n=11) or atorvastatin (n=9) for 4 months. An additional 14 patients were recruited from the same clinic at the same hospital as a control group. The medication of these latter patients was unaltered for 4 months and the same parameters were measured as for the statin group. Antibody titers to Hsp-60, -65, and -70 were measured by enzyme-linked immunosorbent assay and lipoprotein profile and highly sensitive serum C-reactive protein (CRP) were measured by routine methods before and after treatment. Pretreatment and posttreatment data were compared by paired t or Mann-Whitney tests. Overall statin treatment was associated with a significant reduction in median antibody titers to Hsp-60 (17.2%, p=0.03), Hsp-65 (15.9%, p=0.003) and Hsp-70 (8.3%, p=0.006), but not in control patients. Both statins caused a reduction in median serum CRP concentrations (45% overall, p<0.05), but significant changes were not observed in the control patients. The effects on Hsp antibody titers were not related to changes in serum CRP concentrations (p>0.05). However, there was a significant correlation between changes in antibody titers to Hsp-60 vs Hsp-65 (p<0.01), Hsp-60 vs Hsp-70 (p<0.05), and Hsp-65 vs Hsp-70 (p<0.001). Statin treatment was associated with a reduction in antibody titers to Hsp-60, -65, and -70. This reduction is not fully explained by the antiinflammatory effects of the statins but may be due to their other immunomodulatory properties.

A UK general practice population cohort study investigating the association between lipid lowering drugs and 30-day mortality following medically attended acute respiratory illness

Background. Cholesterol lowering drugs HMG-CoA reductase inhibitors (statins) and PPARα activators (fibrates) have been shown to reduce host inflammation via non-disease specific immunomodulatory mechanisms. Recent studies suggest that commonly prescribed drugs in general practice, statins and fibrates, may be beneficial in influenza-like illness related mortality. This retrospective cohort study examines the association between two lipid lowering drugs, statins and fibrates, and all-cause 30-day mortality following a medically attended acute respiratory illness (MAARI). Methods. Primary care patient data were retrospectively extracted from the UK Clinical Practice Research Datalink (CPRD) database. The sample comprised 201,179 adults aged 30 years or older experiencing a MAARI episode. Patient exposure to statins or fibrates was coded as separate dichotomous variables and deemed current if the most recent GP prescription was issued in the 30 days prior to MAARI diagnosis. Multivariable logistic regression and Cox regression were used for analyses. Adjustment was carried out for chronic lung disease, heart failure, metformin and glitazones, comorbidity burden, socio-demographic and lifestyle variables such as smoking status and body mass index (BMI). Statistical interaction tests were carried out to check for effect modification by gender, body mass index, smoking status and comorbidity. Results. A total of 1,096 (5%) patients died within the 30-day follow up period. Of this group, 213 (19.4%) were statin users and 4 (0.4%) were fibrate users. After adjustment, a significant 35% reduction in odds [adj OR; 0.65 (95% CI [0.52-0.80])] and a 33% reduction in the hazard [adj HR: 0.67 (95% CI [0.55-0.83])] of all-cause 30-day mortality following MAARI was observed in statin users. A significant effect modification by comorbidity burden was observed for the association between statin use and MAARI-related mortality. Fibrate use was associated with a non-significant reduction in 30-day MAARI-related mortality. Conclusion. This study suggests that statin use may be associated with a reduction in 30-day mortality following acute respiratory illness that is severe enough to merit medical consultation. Findings from this study support and strengthen similar observational research while providing a strong rationale for a randomised controlled trial investigating the potential role of statins in acute respiratory infections.

HMG-CoA reductase inhibitors in kidney transplant recipients receiving tacrolimus: statins not associated with improved patient or graft survival

Background

The beneficial effects of early statin use in kidney transplant recipients, especially those on tacrolimus-based immunosuppression, are not well established. We evaluated the predictors of statin use following kidney transplantation and examined its association with patient and allograft survival.

Methods

We examined 615 consecutive patients who underwent kidney transplant at our institution between January 1998 and January 2002. Statin use was assessed at baseline and 3, 6, 9, and 12 months following kidney transplant. Patients were followed for allograft and patient survival.

Results

36% of the 615 kidney transplant recipients were treated with statin treatment. Statin use increased over the course of the study period. Older age, elevated body mass index, higher triglyceride levels, hypercholesterolemia, diabetes, history of myocardial infarction were associated with higher rates of statin use; elevated alkaline phosphatase levels and CMV IgG seropositivity were associated with less statin use. Older age, elevated BMI and hypercholesterolemia remained significant predictors of increased statin use after accounting for covariates using multiple regression. The early use of statins was not associated with improvements in unadjusted patient survival [HR 0.99; 95%CI 0.72-1.37] or graft survival [HR 0.97; 95% CI 0.76-1.24]. The risks of death and graft survival were not consistently reduced with exposure to statin using either adjusted models or propensity scores in Cox Proportional Hazards models.

Conclusions

In a kidney transplant population primarily receiving tacrolimus-based immunosuppression, early statin use was not associated with significantly improved graft or patient survival.

Antiretroviral effect of lovastatin on HIV-1-infected individuals without highly active antiretroviral therapy (The LIVE study): a phase-II randomized clinical trial

Background

Highly active antiretroviral therapy produces a significant decrease in HIV-1 replication and allows an increase in the CD4 T-cell count, leading to a decrease in the incidence of opportunistic infections and mortality. However, the cost, side effects and complexity of antiretroviral regimens have underscored the immediate need for additional therapeutic approaches. Statins exert pleiotropic effects through a variety of mechanisms, among which there are several immunoregulatory effects, related and unrelated to their cholesterol-lowering activity that can be useful to control HIV-1 infection.

Methods/design

Randomized, double-blinded, placebo controlled, single-center, phase-II clinical trial. One hundred and ten chronically HIV-1-infected patients, older than 18 years and naïve for antirretroviral therapy (i.e., without prior or current management with antiretroviral drugs) will be enrolled at the outpatient services from the most important centres for health insurance care in Medellin-Colombia. The interventions will be lovastatin (40 mg/day, orally, for 12 months; 55 patients) or placebo (55 patients). Our primary aim will be to determine the effect of lovastatin on viral replication. The secondary aim will be to determine the effect of lovastatin on CD4+ T-cell count in peripheral blood. As tertiary aims we will explore differences in CD8+ T-cell count, expression of activation markers (CD38 and HLA-DR) on CD4 and CD8 T cells, cholesterol metabolism, LFA-1/ICAM-1 function, Rho GTPases function and clinical evolution between treated and not treated HIV-1-infected individuals.

Discussion

Preliminary descriptive studies have suggested that statins (lovastatin) may have anti HIV-1 activity and that their administration is safe, with the potential effect of controlling HIV-1 replication in chronically infected individuals who had not received antiretroviral medications. Considering that there is limited clinical data available on this topic, all these findings warrant further evaluation to determine if long-term administration of statins may benefit the virological and immunological evolution in HIV-1-infected individuals before the use of antiretroviral therapy is required.

Trial registration

Registration number NCT00721305.

Statins induce immunosuppressive effect on heterotopic limb allografts in rat through inhibiting T cell activation and proliferation

Long-term use of immunosuppressive agents could bring many side effects. Recently, 3-Hydroxy-3-methyl-gutaryl coenzyme A reductase inhibitors (statins) have been reported to be immunomodulatory besides lowering serum cholesterol level. The aim of this study was to investigate the effects of statins on composite tissue allografts and T lymphocyte in vivo and in vitro. Rats were divided into 5 groups: syngeneic transplantation group (Lewis-Lewis); allogeneic control group (Brown Norway-Lewis, no treatment); low-dose statins group (15 mg /kg); high-dose statins group (30 mg /kg) and cyclosporin A group. In vivo, treatment of statins significantly prolonged allografts survival as compared to control group. Histological findings further supported these clinical results and demonstrated less extent of rejection. Immunohistochemical analysis showed that there was a remarkably reduced T cells infiltration in statins groups. Moreover, the serum levels of IL-2 and IFN-gamma were decreased after statins therapy, while these in control group increased significantly. Meanwhile, transcriptional activities of IL-2 and IFN-gamma were also dramatically down-regulated after statins treatment. In vitro, mixed lymphocyte reaction assay was performed and the results revealed lymphocyte proliferation was inhibited by statins in a dose-dependent manner. Furthermore, administration of statins exhibited inhibitory effects on CD3/CD28 mediated T cell activation and proliferation. Besides, the results demonstrated that statins significantly down-regulated mRNA expression and suppress cytokine production of IL-2 and IFN-gamma in vitro. In conclusion, our data demonstrated that application of statins could induce immunosuppressive effect and prolong allografts survival through inhibiting activation and proliferation of T cell and reducing production of IL-2 and IFN-gamma.

Inflammation in atherosclerosis and psoriasis: common pathogenic mechanisms and the potential for an integrated treatment approach

Inflammation plays a key role in the pathogenesis of a number of chronic inflammatory systemic diseases (CISDs), including psoriasis, rheumatoid arthritis, systemic lupus erythematosus and Crohn's disease, and also in the pathogenesis of atherosclerosis. CISDs and cardiovascular diseases, such as atherosclerosis, share common pathogenic features, and cardiovascular disease is an important cause of morbidity and mortality in patients with CISDs. Activated inflammatory cells and pro-inflammatory cytokines contribute to the development of psoriatic lesions and play an important role in the breakdown of atherosclerotic plaques. Psoriasis and atherosclerosis also have similar histological characteristics involving T cells, macrophages and monocytes. In particular, the extravasation of T cells through the epithelium is characteristic of both psoriatic and atherosclerotic plaques. Cardiovascular disease is an important cause of morbidity and mortality in patients with psoriasis, which is associated with an increased cardiovascular risk profile compared with the general population. Patients with psoriasis are at increased risk of arterial hypertension, coronary heart disease, hyperlipidaemia, obesity and type II diabetes, which are more prevalent than in control patients. This increased risk could be due to the effects of chronic inflammatory changes, particularly the infiltration of T cells and subsequent secretion of pro-inflammatory cytokines. Some drugs used in the treatment of cardiovascular disease, such as 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and angiotensin-converting enzyme inhibitors have anti-inflammatory activity. In addition, systemic treatments for psoriasis may, by decreasing inflammation, reduce the risk of cardiovascular disease. It is suggested, therefore, that an integrated approach to the treatment of the inflammatory processes underlying both psoriasis and atherosclerosis may be beneficial in reducing cardiovascular risk in patients with psoriasis. The newer targeted biological therapies, such as efalizumab and infliximab, which offer the potential for long-term disease control in psoriasis, may be of particular use in this setting.

Drug insight: autoimmune effects of medications-what's new?

Autoantibodies and lupus-like syndromes can develop following the use of certain medications; however, although many patients develop autoantibodies, only a minority develop clinical features. Although these autoantibodies primarily consist of antinuclear and antihistone antibodies, additional types of antibody, such as antineutrophil cytoplasmic antibodies and anti-double-stranded DNA antibodies, have been reported in association with minocycline and tumor necrosis factor inhibitor therapy. Clinical features of drug-related lupus usually consist of constitutional symptoms, arthralgias, arthritis, myalgias and serositis, although cutaneous manifestations have been reported in association with the use of tumor necrosis factor inhibitors. Typically, clinical features resolve with discontinuation of the medication, although antibodies can persist for months or years. Arthralgias and inflammatory arthritis have also been reported in association with the use of aromatase inhibitors and other biologic agents such as interleukins and interferons.

Protective effects of atorvastatin on chronic allograft nephropathy in rats

OBJECTIVE

Chronic allograft nephropathy (CAN) is the leading cause of late kidney allograft loss. Recent studies have suggested that atorvastatin (ATO) may interact with the acute inflammatory process in the renal interstitium and suppress the proliferation of mesangial cells. We hypothesized that ATO could also inhibit the chronic inflammatory process and prevent the progression of CAN.

MATERIALS AND METHODS

Fisher (F344) kidneys were orthotopically transplanted into Lewis rat recipients. Lewis-to-Lewis rat kidney transplantation was served as the syngeneic control (Syn group). Allograft recipients were randomized and treated with cyclosporine A alone (Allo group) or in combination with ATO (15 or 30 mg/kg/d intrgastric, respectively, the low dose treatment group/high dose treatment group [LT/HT] groups). Renal function and the urine protein excretion were analyzed. Animals were sacrificed 20 weeks posttransplantation for histological and immunohistochemical studies, as well as analysis of mRNA levels of cytokines and chemokines.

RESULTS

Renal function progressively deteriorated and substantial proteinuria developed in the Allo group compared with the Syn group. ATO-treated rats had significantly higher creatinine clearance rate and less amount of proteinuria. Histological examination revealed obvious features of CAN in the Allo group, whereas LT/HT groups demonstrated minimal glomerulosclerosis, interstitial fibrosis, intimal thickening, and tubular atrophy. The numbers of infiltrating mononuclear cells (ED1+, CD8+, and CD68+) decreased markedly, and the intragraft expression of transforming growth factor beta1 (TGF-beta1) and collagen III were also significantly attenuated in the LT/HT groups, as compared with the Allo group. The mRNA levels of proinflammatory cytokines (interleukin-2, interferon-gamma, interleukin-10), chemokines (RANTES, MCP-1), and profibrotic genes (TGF-beta1, collagen III) were significantly down-regulated in ATO-treated rats.

CONCLUSION

Atorvastatin showed excellent favorable effects on blocking renal inflammation and fibrosis, and thus, efficiently inhibited the development and progression of CAN, which might improve the long-term survival rate of renal allografts.

Review article: drug hepatotoxicity

BACKGROUND

Drug toxicity is the leading cause of acute liver failure in the United States. Further understanding of hepatotoxicity is becoming increasingly important as more drugs come to market.

AIMS

(i) To provide an update on recent advances in our understanding of hepatotoxicity of select commonly used drug classes. (ii) To assess the safety of these medications in patients with pre-existing liver disease and in the post-liver transplant setting. (iii) To review relevant advances in toxicogenomics which contribute to the current understanding of hepatotoxic drugs.

METHODS

A Medline search was performed to identify relevant literature using search terms including 'drug toxicity, hepatotoxicity, statins, thiazolidinediones, antibiotics, antiretroviral drugs and toxicogenomics'.

RESULTS

Amoxicillin-clavulanic acid is one of the most frequently implicated causes of drug-induced liver injury worldwide. Statins rarely cause clinically significant liver injury, even in patients with underlying liver disease. Newer thiazolidinediones are not associated with the degree of liver toxicity observed with troglitazone. Careful monitoring for liver toxicity is warranted in patients who are taking antiretrovirals, especially patients who are co-infected with hepatitis B and C. Genetic polymorphisms among enzymes involved in drug metabolism and HLA types may account for some of the differences in individual susceptibility to drug hepatotoxicity.

CONCLUSIONS

Drug-induced hepatotoxicity will remain a problem that carries both clinical and regulatory significance as long as new drugs continue to enter the market. Future results from ongoing multicentre collaborative efforts may help contribute to our current understanding of hepatotoxicity associated with drugs.

[A case of interstitial lung disease with atorvastatin (Tahor) and a review of the literature about these effects observed under statins]

The 3-Hydroxy-3-methyl-glutaryl coenzyme A (HGM-CoA) reductase inhibitors, or statins, are competitive inhibitors of the rate-limiting enzyme in cholesterol synthesis. Generally, statins have an excellent safety profile. Elevations of liver transaminases and creatine phosphokinase with myalgia have been associated with the use of HGM-Co A reductase inhibitors, case reports of rhabdomyolysis are rare, most occurring with concomitant use with other drugs such as cyclosporin, fusidic acid and gemfibrozil. We describe here the clinical case of a patient who developed interstitial lung disease as probably a result of the use of statins which particularly increased with long-term atorvastatin treatment. The present review details some case-reports of interstitial lung disease reported under statins in the literature. Few systemic adverse effects such as lupus-like-syndromes and polymyositis have been reported. Recent experimentations have demonstrated that cholesterol is not the only intracellular target of statins but that they also have a potential role in atherosclerosis and in organ transplantation as immunosuppressor agents.

Ezetimibe in Renal Transplant Patients with Hyperlipidemia Resistant to HMG-CoA Reductase Inhibitors

Hyperlipidemia affects the majority of renal transplant patients. Multiple risk factors contribute to elevated serum cholesterol including the use of certain immunosuppressant agents. HMG-Co A reductase inhibitors have become the preferred class of cholesterol-lowering medication with an increasing body of evidence to support their safety, efficacy, and outcomes in both the normal and renal transplant populations. New guidelines recommend lowering previous LDL-c goals as outcomes appears to continually improve. As a result, ezetimibe has been added to patients with persistently elevated triglycerides and/or LDL-c in individuals who possessed a renal transplant and were deemed to be on a maximum safe dose of statin agent. After the addition of ezetimibe, total cholesterol, LDL-c, and triglycerides fell by 21%, 31%, and 13%, respectively. Creatinine phosphokinase, liver enzyme serum levels, and renal function were not affected to any level of clinical significance with the addition of ezetimibe. Large interpatient variability of measurable immunosuppressant levels was seen but no serious adverse events were attributed to a change in levels.

Effects of atorvastatin on higher functions

OBJECTIVE

This study was undertaken to assess the effects of atorvastatin on cognition and higher mental functions.

METHODS

In this before and after comparison study with controls, group one included 55 subjects aged > or =40 years requiring statins for cardiovascular indications who were started on atorvastatin (10 mg/day). Group two assigned to receive placebo were men and women chosen from the same geographical area and matched for age, sex, education and presence of hypertension and diabetes mellitus. Assessment was done with the Mini-Mental State Examination, Digit Span, Picture Test (average and delayed), Trail Making Test, Controlled Oral Word Association Test, Digit Symbol Substitution Test and Auditory Vigilance and Digit Vigilance Test at baseline and after 6 months. Changes between baseline and 6 months in the above parameters of mental function were compared using suitable statistical tests in the atorvastatin and placebo groups. To limit experiment-wise error, performance scores were grouped into five cognitive domains, which were labeled as attention, psychomotor speed, mental flexibility, working memory and memory retrieval. Summary effect sizes were estimated as z-scores.

RESULTS

Both subjects on atorvastatin and placebo showed improvement in the majority of scales consistent with a learning effect on test performance. However, subjects treated with atorvastatin scored significantly over the placebo group in all domains, i.e. tests of attention [z-score=0.54, 95% confidence interval (CI): 0.38-0.64, p=0.001], psychomotor speed (z-score=0.28, 95% CI: O.09-0.47, p<0.001), mental flexibility (z-score=0.27, 95% CI: 0.22-0.32, p=0.01), working memory (z-score=1.22, 95% CI: 0.93-1.50, p<0.001) and memory retrieval (z-score=0.59, 95% CI: 0.36-0.82, p<0.05).

CONCLUSION

The present study concludes that there are significant beneficial effects of atorvastatin in a dose of 10 mg/day for a period of 6 months on higher functions as measured by the above standard neurocognitive tests.

Statins Could Be Used to Control Replication of Some Viruses, Including HIV-1

Statins are mainly known for their plasma cholesterol-lowering properties and are widely used for the prevention of cardiovascular diseases. They however also exert pleiotropic effects through a variety of mechanisms, among which several immunosuppressive effects that are unrelated to their cholesterol-lowering activity. Interestingly, there has been recent evidence of antiviral effects, including preliminary studies on the efficacy of statins against HIV-1. This paper more particularly focuses on the specific inhibition of the binding of leukocyte function-associated antigen-1 (LFA-1) to intercellular adhesion molecule (ICAM-1) by statins, independently of the inhibition of HMGCoA reductase. Targeting the statin-binding site within LFA-1 or regulating LFA-1 affinity by inhibiting prenylation of the small GTPases could prove useful to treat inflammatory, autoimmune diseases and possibly viral infections, including HIV-1.

HMG CoA reductase inhibitors (statins) to treat Epstein-Barr virus-driven lymphoma

While statins have been highly effective for lowering serum cholesterol and reducing the incidence of coronary events, they have multiple other effects. Certain statins block the interaction of adhesion molecules that are important for cell-cell interactions including those between EBV-transformed B cells. These same statins inhibit NF-kappaB activation in the cells and induce apoptosis of transformed B cells. Studies in severe combined immunodeficiency mice show that simvastatin delays the development of EBV-lymphomas in these animals. These statins might be considered for the treatment of EBV-lymphomas in selected patients.

Immunosuppression: towards a logical approach in liver transplantation

Over the last two decades there has been a significant increase in the number and types of immunosuppressive agents that have been available to clinicians. The protocols for immunosuppression used in liver transplantation have been derived historically from those in renal transplantation. During the last decade there has been a shift in the use of immunosuppression, with the introduction of interleukin (IL)-2 receptor antagonists in place of anti-lymphocyte preparations, substitution of tacrolimus for cyclosporin and mycophenolate for azathioprine. The use of corticosteroids has been reduced. For a variety of reasons, these changes have not always been made on the basis of properly randomized studies. The place of newer agents, such as sirolimus and leflunomide derivatives and of the microbiological agents, is unclear. In this review, we outline briefly the mechanism of action of drugs and suggest possible approaches to the management of the liver allograft recipient, suggesting how treatment could be adjusted according to the indication for transplantation as well as the individual's comorbidities.

Improved lymphocyte function-associated antigen-1 (LFA-1) inhibition by statin derivatives: molecular basis determined by x-ray analysis and monitoring of LFA-1 conformational changes in vitro and ex vivo

The integrin lymphocyte function-associated antigen-1 (LFA-1) (alphaLbeta2; CD11a/CD18) plays an important role in leukocyte migration and T cell activation. LFA-1 is inhibited by the cholesterol-lowering drug lovastatin, which binds to an allosteric site of the alphaL I domain termed the lovastatin site (L-site). Here we report for the first time the x-ray structures of the LFA-1 I domain complexed with derivatives of lovastatin optimized for LFA-1 inhibition. This analysis identified two new subpockets within the L-site occupied by chemical groups of the statin derivatives but not by lovastatin itself. Occupancy of these L-site subpockets led to distinct conformational changes in LFA-1, which were detectable by an epitope-monitoring assay. We utilized this assay to demonstrate improved LFA-1 inhibition in human blood in vitro and in blood samples from treated animals ex vivo. Moreover, we demonstrate that the novel lovastatin-derived LFA-1 inhibitor LFA878 exhibits potent anti-inflammatory effects in carrageenan-induced rat paw edema. In summary, the findings reported here extend the understanding of LFA-1 inhibition at the molecular level, allow for the identification and design of LFA-1 inhibitors of further enhanced potency, and support the expectation that LFA-1 inhibitors binding to the L-site will be of therapeutic value in treating inflammatory diseases.

Immunosuppression for cardiac transplantation—the past, present and future

The field of cardiac transplant immunosuppression is rapidly developing and has evolved over the past 35 years. Anecdote, experience and registry based practice is giving way to an increasing bounty of well designed, randomized controlled trials which will guide future therapy. Current therapy is based on triple therapy with corticosteroids, a calcineurin inhibitor and an antimetabolite, but these regimens may be replaced by substitution or addition of newer antiproliferative agents. The true nemesis is coronary graft vasculopathy, which affects 50% of patients at 5 years and until recently had very few preventive therapeutic options. Renal toxicity remains among the most challenging adverse effects of immunosuppression to be overcome.