MDSC175 Production and critical appraisal of evidence based protocol for immunosuppression


You are required to identify ONLY ONE of the protocols from the list below and engage with the following tasks:

  • Critically reflect on the chosen protocol in your local workplace;
    • How do your local activities in this area relate to the evidence base/guidance (both in your own country and compared to that of other leading centres for transplantation)?;
    • Has there been any shortcomings with the implementation of this protocol, or are there any areas of weakness when considering patient safety and improving outcomes?;
    • What can other centres of transplantation learn from your experience with regard to this protocol?;
    • How might you be able to improve your local practice based on robust evidence to improve patient outcomes?

Protocols available (select one only):

  • Steroid withdrawal protocols.
    • CNI minimisation protocol.
    • mTOR inhibitors in the current practice and protocols.
    • Induction agent(s) in the low-risk group with reference to the local community.
    • Induction agent(s) in a high-risk group with reference to the local community


1.0 Introduction      

1.1 Background

In the contemporary healthcare sector, there has been substantial progress in the area of kidney transplantation. As a consequence, the rates of acute allograft rejection (AR) has declined significantly in the cadaveric and living donors renal transplantation and increased survival of a graft in the first year. As noted by Song et al. report, the rate of graft survival has significantly improved in the initial year of transplantation (1). Further, since the first year of transplantation which happened in the 1960s, there has been increased development and introduction of fresh immunosuppressive agents (Opelz et al., 2).  During the early years of the Kidney transplantation, the immunosuppressant protocols for the kidney transplantation included the total body irradiation steroids and azathioprine (Aza) (Manno, 3). Later in the 1980s, the Cyclosporine A (CyA) which is a Calcineurin Inhibitor (CNI) was developed. This development contributed to an increased reduction in the acute rejection cases and as such noted to significantly improve the level of graft survival in the initial years of transplantation (Mekki et al., 4; Knight, 5). In progressive years, there has been increased development of integrated immunosuppressive medications which are in addition to the already developed induction therapy.  More recently, the Mycophenolate Mofetil (MMF), and Mammalian Target of Rapamycin Inhibitors (M-TORI) were developed and other induction treatments including the anti-thymocyte globulin, basiliximab, daclizumab and the alemtuzumab (Noël et al., 6; Hellemans et al., 7). Additionally, there has been an observed trend of steroid avoidance or minimization through the strategic use of an increased and powerful immunosuppressant. The rationale of the different protocols that are available in different contexts is informed by the fact that the immunosuppressive medications are normally found to be targeting different points in the immune system (Vincenti et al., 8). In particular, the different stages of immunosuppression include the induction, maintenance and treatment of the established rejection process with the induction therapy being critical in the reduction of the acute rejection and assisting in the delay and the use of CNI.

In this report, the selected protocol is the m-TOR inhibitors in the current practice and protocols. Through a reference on this protocol, the local activities have been critically reviewed based on the available literature and best practice globally. Also, the shortcomings of the protocol implementation have been taken into account and the areas of weakness in consideration of patient safety and improving the outcomes. As a strategy of developing a reflection, the best practice that can be learnt by other centres of transplantation in the context of the protocol has been developed. In the end, the best practice based on the evidence available has been reflected with the local practice for improving the patient outcomes.

  • mTOR Inhibitors

The Mammalian target of rapamycin (mTOR) inhibitors has for a long period been noted to be an effective immunosuppressant agent used in the process of renal transplantation. According to Knight (5), ………………………………………………………………………………………………………………………Please contact us through to receive this assessment in full