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April 3, 1987, Vol 257, No. 13 >
ARTICLE | April 3, 1987

Introduction to the Management of Immunosuppression FREE

[+] Author Affiliations

Informational report to the American Medical Association House of Delegates 1986 Annual Meeting.

This report is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all the facts and circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance and patterns of practice evolve. This report reflects the views of the scientific literature as of June 1986.

Reprint requests to Council on Scientific Affairs, American Medical Association, 535 N Dearborn St, Chicago, IL 60610 (William R. Hendee, PhD).


JAMA. 1987;257(13):1781-1785. doi:10.1001/jama.1987.03390130099037
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References

Advances in solid-organ allograft have depended in great measure on the development of improved means of suppressing the immune system of the recipient. This article presents an overview of the major forms of immunosuppression used in organ transplantation, specifically corticosteroids, azathioprine, antilymphocyte and antithymocyte globulin and cyclosporine, monoclonal antibody to the T3 receptor on lymphocytes, and blood transfusions.

(JAMA 1987;257:1781-1785)

REFERENCES

1 +
Starzl TW: Experience in Renal Transplantation . Philadelphia, WB Saunders Co, 1964;.
2 +
Rapaport FT, Dausset J (eds): Human Transplantation . New York, Grune & Stratton, 1968;.
3 +
Najarian JS, Simmons RL (eds): Transplantation . Philadelphia, Lea & Febiger, 1972;.
4 +
Salaman JR: Nonspecific Immunosuppression in Kidney Transplantation Principles and Practice , Morris PJ (ed). New York, Grune & Stratton, 1979;, pp 163-182.
5 +
Tilney NL, Strom TB, Vineyard GB, et al: Factors contributing to the declining mortality rate in renal transplantation. N Engl J Med 1978;;299: 1321-1325.
6 +
Vincenti F, Amend W, Feduska NJ, et al:  Improved outcome following renal transplantation with reduction in the immunosuppression therapy for rejection episodes . Am J Med 1980;;69:107-112.
7 +
McGeown MG, Douglas JF, Brown WA, et al:  Advantages of low-dose steroid from the day after renal transplantation . Transplantation 1980;;29: 287-289.
8 +
Strom TB:  The improving utility of renal transplantation in the management of end-stage renal disease . Am J Med 1982;;73:105-124.
9 +
 Advisory Committee to the Renal Transplant Registry: The 13th report of the Human Renal Transplant Registry . Transpl Proc 1977;;9:9-26.
10 +
 Standards Committee of the American Society of Transplant Surgeons: Current results and expectations of renal transplantation . JAMA 1981;;246: 1330-1331.
11 +
Najarian JS, Simmons RL, Condie RM, et al:  Seven years experience with antilymphoblast globulin for renal transplantation from cadaver donors . Ann Surg 1976;;184:352-368.
12 +
Opelz G, Terasaki PI:  Dominant effect of transfusions on kidney graft survival . Transplantation 1980;;29:153-158.
13 +
Salvatierra O Jr, Vincenti F, Amend W, et al:  Deliberate donor specific blood transfusions prior to living-related renal transplantation: A new approach . Ann Surg 1980;;192:543-552.
14 +
Pfaff WM, Fermell RS, Howard RJ, et al:  Planned random donor blood transfusion in preparation for transplantation . Transplantation 1984;; 38:701-703.
15 +
Anderson CB, Sicard GA, Etheredge EE:  Pretreatment of renal allograft recipients with azathioprine and donor-specific blood products . Surgery 1982;;92:315-321.
16 +
Caine RY, White DJG, Thiru S, et al:  Cyclosporin A in patients receiving renal allografts from cadaver donors . Lancet 1978;;2:1323-1327.
17 +
Starzl TE, Hakala TR, Rosenthal JT, et al:  The Colorado-Pittsburgh cadaveric renal transplantation study with cyclosporine . Transpl Proc 1983;; 15:2459-2462.
18 +
European Multicentre Trial Group:  Cyclosporin in cadaveric renal transplantation: One year follow up of a multicentre trial . Lancet 1983;;2: 986-989.
19 +
 Canadian Multicentre Transplant Study Group: A randomized clinical trial of cyclosporine in cadaveric renal transplantation . N Engl J Med 1983;;309:809-815.
20 +
Kahan BD:  Cyclosporine: A powerful addition to the immunosuppressive armamentarium . Am J Kidney Dis 1984;;3:444-455.
21 +
Braun WE:  Renal allograft rejection , in Bay-less TM, Brain MC, Cherniak RM (eds): Current Therapy in Internal Medicine, 1984-1985 . Philadelphia, BC Decker Inc, 1984;, pp 1249-1257.
22 +
Streem SB, Novick AC, Braun WE, et al:  Low-dose maintenance prednisone and antilymphoblast globulin for the treatment of acute rejection . Transplantation 1983;;35:420-424.
23 +
Dunnill MS:  Histopathology of rejection in renal transplantation , in Morris PJ (ed): Kidney Transplantation: Principles and Practice . New York, Grune & Stratton, 1979;, pp 225-249.
24 +
Zoller KM, Cho SI, Cohen JJ, et al:  Cessation of immunosuppressive therapy after successful transplantation: A national survey . Kidney Int 1980;;18:110-114.
25 +
First MR, Munda R, Kant KS, et al:  Steroid withdrawal following HLA-identical related donor transplantation . Transpl Proc 1981;;13:319-322.
26 +
Claman HN:  Glucocorticosteroids: II. The clinical responses . Hosp Practice , (July) 1983;, pp 143-151.
27 +
Penn I:  Lymphomas complicating organ transplantation . Transpl Proc 1983;;15( (suppl 1) ):2790-2797.
28 +
Bulkley BH, Robert WC:  The heart in systemic lupus erythematosus and the changes induced in it by corticosteroid therapy . Am J Med 1975;;52: 243-264.
29 +
Stubbs SS, Movall RM:  Intravenous methylprednisolone sodium succinate: Adverse reactions reported in association with immunosuppressive therapy . Transpl Proc 1973;;5:1145-1146.
30 +
McGougal BA, Whittier FC, Cross DE:  Sudden death after bolus steroid therapy for acute rejection . Transpl Proc 1976;;8:493-496.
31 +
Woods JE, Zincke H, Palumbo PJ, et al:  Hyperosmolar nonketotic syndrome and steroid diabetics: Occurrence after renal transplantation . JAMA 1975;;231:1261-1263.
32 +
Cupps TR, Fauci AS:  Corticosteroid-mediated immunoregulation in man . Immunol Rev 1982;;65: 133-155.
33 +
Claman HN:  Glucocorticosteroids: I. Anti-inflammatory mechanisms . Hosp Practice , (July) 1983;, pp 123-134.
34 +
Knudsen PJ, Strom TB:  Glucocorticoids inhibit transcription of interleukin 1—encoding RNA . Read before the American Society of Nephrology , New Orleans, (Dec 18) , 1985;.
35 +
Hardt C, Rollinghoff M, Pfizenmaier K, et al:  Lyt-23 + cyclophosphamide-sensitive T cells regulate the activity of an interleukin 2 inhibitor in vivo . J Exp Med 1981;;154:262-274.
36 +
Elion GB, Callahan SW, Hitchings GH, et al:  Experimental, clinical, and metabolic studies of thiopurines . Cancer Chemother 1962;;16:197-202.
37 +
 Analgesic - antipretics, anti - inflammatory agents, and inhibitors of uric acid synthesis , in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics . New York, Macmillan Publishing Co Inc, 1970;, pp 314-347.
38 +
 Aklylating agents, antimetabolites, hormones, and other antiproliferative agents , in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics . New York, Macmillan Publishing Co Inc, 1970;, pp 1348-1395.
39 +
Halloran P, Ludwin D, April M, et al:  Randomized comparison between cyclosporine and conventional therapy plus Minnesota anti-lymphocyte globulin in cadaveric renal transplantation . Transpl Proc 1983;;15:2513-2516.
40 +
Sutherland DER, Strand M, Fryd DS, et al:  Comparison of azathioprine-antilymphocyte globulin versus cyclosporine in renal transplantation . Am J Kidney Dis 1984;;3:456-461.
41 +
Shied CF III, Cosimi AB, Tolkoff-Rubin, et al:  Use of antithymocyte globulin for reversal of acute allograft rejection . Transplantation 1979;;28:461-464.
42 +
Hoitsma AJ, Reekers P, Kreeftenberg H, et al:  Treatment of acute rejection of cadaveric renal allografts with rabbit antithymocyte globulin . Transplantation 1982;;33:12-16.
43 +
Gewurz H, Pickering RJ, Moberg A, et al:  Reactivities to horse anti-lymphocyte globulin . Int Arch Allergy 1970;;39:210-220.
44 +
Monaco AP:  Antilymphocyte globulin: A Clinical transplantation research opportunity . Am J Kidney Dis 1982;;2:67-78.
45 +
Cohen DJ, Loertscher R, Rubin MF, et al:  Cyclosporine: A new immunosuppressive agent for organ transplantation . Ann Intern Med 1984;;101: 667-682.
46 +
Venkataramanan R, Starzl TE, Yang S, et al:  Biliary excretion of cyclosporine in liver transplant patients . Transpl Proc 1985;;17:286-289.
47 +
Elliott JF, Lin Y, Mizel SB, et al:  Induction of interleukin 2 messenger RNA inhibited by cyclosporin A . Science 1984;;226:1439-1441.
48 +
Tilney NL, Milford EL, Aranjo JL, et al:  Experience with cyclosporine and steroids in clinical renal transplantation . Ann Surg 1984;;200: 605-613.
49 +
Sommer BG, Ferguson RM:  Three immediate postrenal transplant adjunct protocols combined with maintenance cyclosporine . Transpl Proc 1985;;17:1235-1238.
50 +
Canafax DM, Martel EJ, Ascher NL, et al:  Two methods of managing cyclosporine nephrotoxicity: Conversion to azathioprine, prednisone, or cyclosporine, azathioprine, and prednisone . Transpl Proc 1985;;17:1176-1177.
51 +
Illner WD, Land W, Habersetzer R, et al:  Cyclosporine in combination with azathioprine and steroids in cadaveric renal transplantation . Transpl Proc 1985;;17:1181-1184.
52 +
Myers BD, Ross J, Newton L, et al:  Cyclosporine-associated chronic nephropathy . N Engl J Med 1984;;311:699-705.
53 +
Bennett WM:  Basic mechanisms and pathophysiology of cyclosporine nephrotoxicity . Transpl Proc 1985;;17( (suppl 1) ):297-302.
54 +
Kohler G, Milstein C:  Continuous cultures of fused cells secreting antibody of predefined specificity . Nature 1975;;259:495-497.
55 +
Cosimi AB, Calvin RB, Burton RC, et al:  Use of monoclonal antibodies to T cell subsets for immunologic monitoring and treatment in recipients of renal allografts . N Engl J Med 1981;;305: 308-314.
56 +
Ortho Multicentre Transplant Study Group:  A randomized clinical trial of OKT3 monoclonal antibody for acute rejection of cadaveric renal transplants . N Engl J Med 1985;;313:337-343.
57 +
Starzl TE, Fung JJ:  Introduction: Reversal of acute renal allograft rejection with KT3 . Dateline: Issues in Transplantation 1985;;1( (summer) /fall):2-4.
58 +
Norman DJ:  Reversal of acute renal allograft rejection with OKT3 . Dateline: Issues in Transplantation 1985;;1( (summer) /fall):5-17.
59 +
Besarab A, Jarrell B, Ihle BU, et al:  Adverse effects of prophylactic irradiation and acute tubular necrosis on renal graft function and survival . Nephron 1982;;31:347-353.
60 +
Sampson D, Levin BS, Hoppe RT, et al:  Preliminary observations on the use of total lymphoid irradiation, rabbit antithymocyte globulin and low dose prednisone in human cadaver renal transplan tation . Transpl Proc 1985;;17:1299-1303.
61 +
Starzl TE, Weil R III, Koep LJ, et al:  Thoracic duct fistula and renal transplantation . Ann Surg 1979;;190:474-486.
62 +
Pilepich MV, Sicard GA, Breauz SR, et al:  Renal graft irradiation in acute rejection . Transplantation 1983;;35:208-211.
63 +
Allen NH, Dyer P, Geoghegan T, et al:  Plasma exchange in acute renal allograft rejection: A controlled study . Transplantation 1983;;35:425-428.
64 +
Aljani MR, Pechan BW, Dan F, et al:  Treatment of steroid-resistant renal allograft rejection with plasmaleukapheresis . Transpl Proc 1983;;15: 1063-1066.
65 +
Cardella CJ, Sutton DM, Falk JA, et al:  A controlled trial evaluating intensive plasma exchange in renal transplantation . Eur Dial Transpl Assoc 1980;;17:429-434.
66 +
Council on Scientific Affairs:  Current status of therapeutic plasmapheresis and related techniques: Report of the AMA Panel on Therapeutic Plasmapheresis . JAMA 1985;;253:819-825.
67 +
Griffin PJA, Salaman JR:  A controlled trial of heparin in renal transplant rejection . Transplantation 1981;;32:306-307.
68 +
Kincaid-Smith P:  Modification of the vascular lesions of rejection in cadaveric renal allografts by dipyridamole and anticoagulants . Lancet 1969;;2: 920-922.
69 +
Clyne DH, Kincaid-Smith P, Ribush NT, et al:  Improvement in renal blood flow of rejecting renal allografts during heparin infusion . Med J Aust 1970;;1:522-524.
70 +
Dosekun AK, First MR, Chandran PKG, et al:  Successful treatment by defibrination with ancrod in a patient with hyperacute renal allograft failure and a deficiency of plasma prostacyclin stimulating factor . Clin Nephrol 1982;;18:101-105.
71 +
MacDonald AS, Balitsky P, Cohen A, et al:  Cyclosporine for steroid-resistant rejection in azathioprine-treated renal recipients . Transpl Proc 1983;;15:2535-2537.
72 +
Fine RN, Terasaki PI, Ettenger RB, et al:  Renal transplantation update . Ann Intern Med 1984;;100:246-257.
73 +
Lenhard V, Massen G, Seifert P, et al:  Characterization of transfusion-induced suppressor cells in prospective kidney allograft recipients . Transpl Proc 1982;;14:329-332.
74 +
Singal DO, Joseph S:  Role of blood transfusions on the induction of antibodies against recognition sites on T lymphocytes in renal transplant recipients . Hum Immunol 1982;;4:93-108.
75 +
Flechner S, Kerman RH, Van Buren CT, et al:  The use of cyclosporine A for high MLC haploidentical living-related transplants . Transpl Proc 1983;; 15:442-445.
76 +
Fryd DS, Sutherland DER, Simmons RL, et al:  Results of a prospective randomized study on the effect of splenectomy versus no splenectomy in renal transplant patients . Transpl Proc 1981;;13: 48-56.
77 +
Sutherland DER, Fryd DS, So SKS, et al:  Long-term effect of splenectomy versus no splenectomy in renal transplant patients . Transplantation 1984;;38:619-624.

Figures

Tables

Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Starzl TW: Experience in Renal Transplantation . Philadelphia, WB Saunders Co, 1964;.
2 +
Rapaport FT, Dausset J (eds): Human Transplantation . New York, Grune & Stratton, 1968;.
3 +
Najarian JS, Simmons RL (eds): Transplantation . Philadelphia, Lea & Febiger, 1972;.
4 +
Salaman JR: Nonspecific Immunosuppression in Kidney Transplantation Principles and Practice , Morris PJ (ed). New York, Grune & Stratton, 1979;, pp 163-182.
5 +
Tilney NL, Strom TB, Vineyard GB, et al: Factors contributing to the declining mortality rate in renal transplantation. N Engl J Med 1978;;299: 1321-1325.
6 +
Vincenti F, Amend W, Feduska NJ, et al:  Improved outcome following renal transplantation with reduction in the immunosuppression therapy for rejection episodes . Am J Med 1980;;69:107-112.
7 +
McGeown MG, Douglas JF, Brown WA, et al:  Advantages of low-dose steroid from the day after renal transplantation . Transplantation 1980;;29: 287-289.
8 +
Strom TB:  The improving utility of renal transplantation in the management of end-stage renal disease . Am J Med 1982;;73:105-124.
9 +
 Advisory Committee to the Renal Transplant Registry: The 13th report of the Human Renal Transplant Registry . Transpl Proc 1977;;9:9-26.
10 +
 Standards Committee of the American Society of Transplant Surgeons: Current results and expectations of renal transplantation . JAMA 1981;;246: 1330-1331.
11 +
Najarian JS, Simmons RL, Condie RM, et al:  Seven years experience with antilymphoblast globulin for renal transplantation from cadaver donors . Ann Surg 1976;;184:352-368.
12 +
Opelz G, Terasaki PI:  Dominant effect of transfusions on kidney graft survival . Transplantation 1980;;29:153-158.
13 +
Salvatierra O Jr, Vincenti F, Amend W, et al:  Deliberate donor specific blood transfusions prior to living-related renal transplantation: A new approach . Ann Surg 1980;;192:543-552.
14 +
Pfaff WM, Fermell RS, Howard RJ, et al:  Planned random donor blood transfusion in preparation for transplantation . Transplantation 1984;; 38:701-703.
15 +
Anderson CB, Sicard GA, Etheredge EE:  Pretreatment of renal allograft recipients with azathioprine and donor-specific blood products . Surgery 1982;;92:315-321.
16 +
Caine RY, White DJG, Thiru S, et al:  Cyclosporin A in patients receiving renal allografts from cadaver donors . Lancet 1978;;2:1323-1327.
17 +
Starzl TE, Hakala TR, Rosenthal JT, et al:  The Colorado-Pittsburgh cadaveric renal transplantation study with cyclosporine . Transpl Proc 1983;; 15:2459-2462.
18 +
European Multicentre Trial Group:  Cyclosporin in cadaveric renal transplantation: One year follow up of a multicentre trial . Lancet 1983;;2: 986-989.
19 +
 Canadian Multicentre Transplant Study Group: A randomized clinical trial of cyclosporine in cadaveric renal transplantation . N Engl J Med 1983;;309:809-815.
20 +
Kahan BD:  Cyclosporine: A powerful addition to the immunosuppressive armamentarium . Am J Kidney Dis 1984;;3:444-455.
21 +
Braun WE:  Renal allograft rejection , in Bay-less TM, Brain MC, Cherniak RM (eds): Current Therapy in Internal Medicine, 1984-1985 . Philadelphia, BC Decker Inc, 1984;, pp 1249-1257.
22 +
Streem SB, Novick AC, Braun WE, et al:  Low-dose maintenance prednisone and antilymphoblast globulin for the treatment of acute rejection . Transplantation 1983;;35:420-424.
23 +
Dunnill MS:  Histopathology of rejection in renal transplantation , in Morris PJ (ed): Kidney Transplantation: Principles and Practice . New York, Grune & Stratton, 1979;, pp 225-249.
24 +
Zoller KM, Cho SI, Cohen JJ, et al:  Cessation of immunosuppressive therapy after successful transplantation: A national survey . Kidney Int 1980;;18:110-114.
25 +
First MR, Munda R, Kant KS, et al:  Steroid withdrawal following HLA-identical related donor transplantation . Transpl Proc 1981;;13:319-322.
26 +
Claman HN:  Glucocorticosteroids: II. The clinical responses . Hosp Practice , (July) 1983;, pp 143-151.
27 +
Penn I:  Lymphomas complicating organ transplantation . Transpl Proc 1983;;15( (suppl 1) ):2790-2797.
28 +
Bulkley BH, Robert WC:  The heart in systemic lupus erythematosus and the changes induced in it by corticosteroid therapy . Am J Med 1975;;52: 243-264.
29 +
Stubbs SS, Movall RM:  Intravenous methylprednisolone sodium succinate: Adverse reactions reported in association with immunosuppressive therapy . Transpl Proc 1973;;5:1145-1146.
30 +
McGougal BA, Whittier FC, Cross DE:  Sudden death after bolus steroid therapy for acute rejection . Transpl Proc 1976;;8:493-496.
31 +
Woods JE, Zincke H, Palumbo PJ, et al:  Hyperosmolar nonketotic syndrome and steroid diabetics: Occurrence after renal transplantation . JAMA 1975;;231:1261-1263.
32 +
Cupps TR, Fauci AS:  Corticosteroid-mediated immunoregulation in man . Immunol Rev 1982;;65: 133-155.
33 +
Claman HN:  Glucocorticosteroids: I. Anti-inflammatory mechanisms . Hosp Practice , (July) 1983;, pp 123-134.
34 +
Knudsen PJ, Strom TB:  Glucocorticoids inhibit transcription of interleukin 1—encoding RNA . Read before the American Society of Nephrology , New Orleans, (Dec 18) , 1985;.
35 +
Hardt C, Rollinghoff M, Pfizenmaier K, et al:  Lyt-23 + cyclophosphamide-sensitive T cells regulate the activity of an interleukin 2 inhibitor in vivo . J Exp Med 1981;;154:262-274.
36 +
Elion GB, Callahan SW, Hitchings GH, et al:  Experimental, clinical, and metabolic studies of thiopurines . Cancer Chemother 1962;;16:197-202.
37 +
 Analgesic - antipretics, anti - inflammatory agents, and inhibitors of uric acid synthesis , in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics . New York, Macmillan Publishing Co Inc, 1970;, pp 314-347.
38 +
 Aklylating agents, antimetabolites, hormones, and other antiproliferative agents , in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics . New York, Macmillan Publishing Co Inc, 1970;, pp 1348-1395.
39 +
Halloran P, Ludwin D, April M, et al:  Randomized comparison between cyclosporine and conventional therapy plus Minnesota anti-lymphocyte globulin in cadaveric renal transplantation . Transpl Proc 1983;;15:2513-2516.
40 +
Sutherland DER, Strand M, Fryd DS, et al:  Comparison of azathioprine-antilymphocyte globulin versus cyclosporine in renal transplantation . Am J Kidney Dis 1984;;3:456-461.
41 +
Shied CF III, Cosimi AB, Tolkoff-Rubin, et al:  Use of antithymocyte globulin for reversal of acute allograft rejection . Transplantation 1979;;28:461-464.
42 +
Hoitsma AJ, Reekers P, Kreeftenberg H, et al:  Treatment of acute rejection of cadaveric renal allografts with rabbit antithymocyte globulin . Transplantation 1982;;33:12-16.
43 +
Gewurz H, Pickering RJ, Moberg A, et al:  Reactivities to horse anti-lymphocyte globulin . Int Arch Allergy 1970;;39:210-220.
44 +
Monaco AP:  Antilymphocyte globulin: A Clinical transplantation research opportunity . Am J Kidney Dis 1982;;2:67-78.
45 +
Cohen DJ, Loertscher R, Rubin MF, et al:  Cyclosporine: A new immunosuppressive agent for organ transplantation . Ann Intern Med 1984;;101: 667-682.
46 +
Venkataramanan R, Starzl TE, Yang S, et al:  Biliary excretion of cyclosporine in liver transplant patients . Transpl Proc 1985;;17:286-289.
47 +
Elliott JF, Lin Y, Mizel SB, et al:  Induction of interleukin 2 messenger RNA inhibited by cyclosporin A . Science 1984;;226:1439-1441.
48 +
Tilney NL, Milford EL, Aranjo JL, et al:  Experience with cyclosporine and steroids in clinical renal transplantation . Ann Surg 1984;;200: 605-613.
49 +
Sommer BG, Ferguson RM:  Three immediate postrenal transplant adjunct protocols combined with maintenance cyclosporine . Transpl Proc 1985;;17:1235-1238.
50 +
Canafax DM, Martel EJ, Ascher NL, et al:  Two methods of managing cyclosporine nephrotoxicity: Conversion to azathioprine, prednisone, or cyclosporine, azathioprine, and prednisone . Transpl Proc 1985;;17:1176-1177.
51 +
Illner WD, Land W, Habersetzer R, et al:  Cyclosporine in combination with azathioprine and steroids in cadaveric renal transplantation . Transpl Proc 1985;;17:1181-1184.
52 +
Myers BD, Ross J, Newton L, et al:  Cyclosporine-associated chronic nephropathy . N Engl J Med 1984;;311:699-705.
53 +
Bennett WM:  Basic mechanisms and pathophysiology of cyclosporine nephrotoxicity . Transpl Proc 1985;;17( (suppl 1) ):297-302.
54 +
Kohler G, Milstein C:  Continuous cultures of fused cells secreting antibody of predefined specificity . Nature 1975;;259:495-497.
55 +
Cosimi AB, Calvin RB, Burton RC, et al:  Use of monoclonal antibodies to T cell subsets for immunologic monitoring and treatment in recipients of renal allografts . N Engl J Med 1981;;305: 308-314.
56 +
Ortho Multicentre Transplant Study Group:  A randomized clinical trial of OKT3 monoclonal antibody for acute rejection of cadaveric renal transplants . N Engl J Med 1985;;313:337-343.
57 +
Starzl TE, Fung JJ:  Introduction: Reversal of acute renal allograft rejection with KT3 . Dateline: Issues in Transplantation 1985;;1( (summer) /fall):2-4.
58 +
Norman DJ:  Reversal of acute renal allograft rejection with OKT3 . Dateline: Issues in Transplantation 1985;;1( (summer) /fall):5-17.
59 +
Besarab A, Jarrell B, Ihle BU, et al:  Adverse effects of prophylactic irradiation and acute tubular necrosis on renal graft function and survival . Nephron 1982;;31:347-353.
60 +
Sampson D, Levin BS, Hoppe RT, et al:  Preliminary observations on the use of total lymphoid irradiation, rabbit antithymocyte globulin and low dose prednisone in human cadaver renal transplan tation . Transpl Proc 1985;;17:1299-1303.
61 +
Starzl TE, Weil R III, Koep LJ, et al:  Thoracic duct fistula and renal transplantation . Ann Surg 1979;;190:474-486.
62 +
Pilepich MV, Sicard GA, Breauz SR, et al:  Renal graft irradiation in acute rejection . Transplantation 1983;;35:208-211.
63 +
Allen NH, Dyer P, Geoghegan T, et al:  Plasma exchange in acute renal allograft rejection: A controlled study . Transplantation 1983;;35:425-428.
64 +
Aljani MR, Pechan BW, Dan F, et al:  Treatment of steroid-resistant renal allograft rejection with plasmaleukapheresis . Transpl Proc 1983;;15: 1063-1066.
65 +
Cardella CJ, Sutton DM, Falk JA, et al:  A controlled trial evaluating intensive plasma exchange in renal transplantation . Eur Dial Transpl Assoc 1980;;17:429-434.
66 +
Council on Scientific Affairs:  Current status of therapeutic plasmapheresis and related techniques: Report of the AMA Panel on Therapeutic Plasmapheresis . JAMA 1985;;253:819-825.
67 +
Griffin PJA, Salaman JR:  A controlled trial of heparin in renal transplant rejection . Transplantation 1981;;32:306-307.
68 +
Kincaid-Smith P:  Modification of the vascular lesions of rejection in cadaveric renal allografts by dipyridamole and anticoagulants . Lancet 1969;;2: 920-922.
69 +
Clyne DH, Kincaid-Smith P, Ribush NT, et al:  Improvement in renal blood flow of rejecting renal allografts during heparin infusion . Med J Aust 1970;;1:522-524.
70 +
Dosekun AK, First MR, Chandran PKG, et al:  Successful treatment by defibrination with ancrod in a patient with hyperacute renal allograft failure and a deficiency of plasma prostacyclin stimulating factor . Clin Nephrol 1982;;18:101-105.
71 +
MacDonald AS, Balitsky P, Cohen A, et al:  Cyclosporine for steroid-resistant rejection in azathioprine-treated renal recipients . Transpl Proc 1983;;15:2535-2537.
72 +
Fine RN, Terasaki PI, Ettenger RB, et al:  Renal transplantation update . Ann Intern Med 1984;;100:246-257.
73 +
Lenhard V, Massen G, Seifert P, et al:  Characterization of transfusion-induced suppressor cells in prospective kidney allograft recipients . Transpl Proc 1982;;14:329-332.
74 +
Singal DO, Joseph S:  Role of blood transfusions on the induction of antibodies against recognition sites on T lymphocytes in renal transplant recipients . Hum Immunol 1982;;4:93-108.
75 +
Flechner S, Kerman RH, Van Buren CT, et al:  The use of cyclosporine A for high MLC haploidentical living-related transplants . Transpl Proc 1983;; 15:442-445.
76 +
Fryd DS, Sutherland DER, Simmons RL, et al:  Results of a prospective randomized study on the effect of splenectomy versus no splenectomy in renal transplant patients . Transpl Proc 1981;;13: 48-56.
77 +
Sutherland DER, Fryd DS, So SKS, et al:  Long-term effect of splenectomy versus no splenectomy in renal transplant patients . Transplantation 1984;;38:619-624.

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To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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