Modern immunosuppression

Successful organ transplantation offers improved survival and quality of life to patients with end-stage organ failure. Following transplantation, the recipient's immune system is exposed to non-self human leucocyte antigens expressed on the donor organ that can trigger a rejection response. Overcoming this potential for rejection is key to a successful outcome. However, the immunosuppressive medications required to prevent rejection come with inherent side effects that can reduce long-term graft and patient survival. Mechanisms of rejection are, briefly, discussed in order to understand how immunosuppressive medications act. The mechanisms of action, benefits and side effects of commonly used induction and maintenance agents are highlighted. Immunosuppression is typically protocol driven initially but evolves with an individual recipient's clinical course and factors to take into consideration are discussed. Finally, we review emerging therapies entering the immunosuppressive repertoire including complement pathway inhibitors, plasma cell depleting agents and cellular therapies that have the potential to drive the next step change in improved transplant outcomes.