Withdrawal of immunosuppression: implications for composite tissue allograft transplantation.

Complete or partial withdrawal of immunosuppression is a desirable goal for physicians managing solid organ transplant recipients and has particular appeal for the management of composite tissue allograft recipients. Experience to date with steroid withdrawal or cyclosporine withdrawal in organ transplant recipients suggests that the risks of acute rejection are minimized with slow tapering of the drugs and when drug withdrawal is attempted many months or years after transplantation. Unfortunately, the full benefits of withdrawing any component of a multidrug immunosuppression regimen can probably be achieved only when the drug is withdrawn relatively early after transplantation. Thus, there is a need for improved immunologic monitoring to facilitate withdrawal of immunosuppression in any setting. Because steroid withdrawal might be particularly advantageous to the recipient of a composite tissue allograft, further experience is needed to determine the safety of steroid withdrawal with newer immunosuppressants such as tacrolimus, mycophenolate mofetil, and sirolimus.