Priority 11 from the Kidney Transplant PSP

UNCERTAINTY: Which combinations of immunosuppressive drugs can minimise side effects in kidney transplant recipients (such as infections, diarrhoea, malignancy)?
Overall ranking	Priority questions agreed on but not put in ranked order
JLA question ID	0037/11
Explanatory note	Not available for this PSP
Evidence	Existing Systematic Reviews: Knoll, G. A., Kokolo, M. B., Mallick, R., Beck, A., Buenaventura, C. D., Ducharme, R., Barsoum, R., Bernasconi, C., Blydt-Hansen, T. D., Ekberg, H., et al. Effect of sirolimus on malignancy and survival after kidney transplantation: systematic review and meta-analysis of individual patient data. BMJ. 2014;349:g6679 PMID: 25422259 ~ Morgan, R. D., O'Callaghan, J. M., Knight, S. R., Morris, P. J.. Alemtuzumab Induction Therapy in Kidney Transplantation: A Systematic Review and Meta-Analysis. Transplantation. 2012;93(12):1179-1188 PMID: 22660659 ~ Webster, AC., Ruster, LP., McGee, R, Matheson, SL., Higgins, GY., Willis, NS., Chapman, JR., Craig, JC. Interleukin 2 receptor antagonists for kidney transplant recipients. Cochrane Database of Systematic Reviews. 2010;(1):CD003897 PMID: 20091551 ~ Knight, S. R., Russell, N. K., Barcena, L., Morris, P. J. Mycophenolate mofetil decreases acute rejection and may improve graft survival in renal transplant recipients when compared with azathioprine: a systematic review. Transplantation. 2009;87(6):785-94 PMID: 19300178 ~ Webster AC, Taylor RRS, Chapman JR and Craig JC. Tacrolimus versus cyclosporin as primary immunosuppression for kidney transplant recipients. Cochrane Database of Systematic Reviews 2005. CD003961 ~ Knight, S R., Morris, P J. Steroid avoidance or withdrawal after renal transplantation increases the risk of acute rejection but decreases cardiovascular risk. A meta-analysis. Transplantation. 2010;89(1):1-14 PMID: 20061913 Ongoing Systematic Reviews: Hutton, B., Joseph, L., Yazdi, F., Tetzlaff, J., Hersi, M., Kokolo, M., Fergusson, N., Bennett, A., Buenaventura, C. D., Fergusson, D., et al. Checking whether there is an increased risk of post-transplant lymphoproliferative disorder and other cancers with specific modern immunosuppression regimens in renal transplantation: Protocol for a network meta-analysis of randomized and observational studies. Systematic Reviews. 2014;3(1):16 PROSPERO Registration Number: CRD42013006951
Health Research Classification System category	Renal and Urogenital

Extra information provided by this PSP
Original uncertainty examples	Does immunosuppression increase the risk of cardiovascular disease when compared to a GFR-matched cohort with CKD? Are their any anti-rejection drugs without side effects What side effects the medication has after transplant ? What do some patients get diarrhoea or recurrent infections on MMF? What changes have there been in anti-rejection drugs in past 20 years and have the side effects improved? How will immunosuppression impact on my life after my transplant? Why aren't patients given more advice on serious life threatening side effects of immuno suppression drugs? What drugs will I need to take after a having a kidney transplant or becoming a living donor and what effects can these drugs have? Please can an answer be found to deal with bowel upset that seems to be unavoidable with mycophenolate? How the side effects of anti-rejection drugs can be lessened e.g. muscle cramps Side effects of anti rejection drugs Do we need MMF/MPA in long term imunosupresion?
Comparison	Drug
Submitted by	Patients x 8 Carers x 1 Clinicians x 3
Outcomes to be measured	Drug side effects, adverse events

PSP information
PSP unique ID	0037
PSP name	Kidney Transplant
Total number of uncertainties identified by this PSP.	90 (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop	3 February 2016