THE PACE of transplantation has accelerated from a crawl to a sprint since the advent of cyclosporine. But a decade out of the starting blocks, this immuno-suppressant's Achilles' heel, renal toxicity, is beginning to throb.
Whether this throb will prove manageable with lower doses and careful monitoring or will eventually disqualify this lifesaving drug from long-term immunosuppression therapy has fueled a long-standing controversy within the transplantation community.
Most needed and yet noticeably absent from these debates has been the element of time. Patient and graft survival curves when cyclosporine is used extend 9 or 10 years at most, yet endstage renal failure can take decades to develop.
Hypertension, hypercholesterolemia, and diabetes—other risk factors associated with the concomitant use of steroids—also loom over the survival curves. How many years after transplantation, if ever, will the penalty paid by the "innocent bystanders," that is, the nontransplanted organs, outweigh the benefits?