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Immunosuppression

Immunosuppression refers to the reduction in the activation or efficacy of the innate and humoral immune response, which can occur naturally due to infections or diseases like HIV, or be induced deliberately through drugs, radiation, or other interventions to prevent immune-mediated damage.^[1] In medicine, immunosuppression is most commonly employed to prevent organ transplant rejection and to treat autoimmune diseases, where the immune system erroneously attacks the body's own tissues, such as in rheumatoid arthritis, lupus, or multiple sclerosis.^[2] Common applications include solid organ transplantation (e.g., kidney, heart, liver) and management of inflammatory conditions, with regimens tailored to balance efficacy against risks.^[2] Historical milestones include the discovery of cortisol's immunosuppressive effects in 1949, leading to glucocorticoid use, followed by cyclosporine in 1976, which revolutionized transplant success rates by inhibiting T-cell activation.^[2] Immunosuppressive agents are broadly classified into several categories based on their mechanisms: calcineurin inhibitors (e.g., cyclosporine and tacrolimus), which block T-cell signaling pathways; mTOR inhibitors (e.g., sirolimus and everolimus), which halt cell proliferation by targeting the mammalian target of rapamycin; antiproliferative agents (e.g., azathioprine and mycophenolate mofetil), which interfere with DNA synthesis in lymphocytes; corticosteroids (e.g., prednisone), which reduce inflammation and immune cell activity; and biologics (e.g., rituximab and alemtuzumab), which deplete specific immune cells like B or T lymphocytes.^[2] These drugs often work synergistically in multidrug protocols to achieve targeted suppression while minimizing toxicity.^[2] While effective, immunosuppression carries significant risks, including heightened susceptibility to infections due to impaired pathogen clearance, increased malignancy rates (e.g., non-Hodgkin lymphoma up to 60-fold higher with azathioprine use), and virus-associated cancers like Kaposi sarcoma in transplant recipients.^[1] Other adverse effects encompass nephrotoxicity (particularly from calcineurin inhibitors), hypertension, hyperlipidemia, diabetes, and cardiovascular complications, necessitating lifelong monitoring and dose adjustments.^[2] In pregnancy, agents like steroids and tacrolimus elevate risks of gestational diabetes and hypertension, underscoring the need for individualized risk-benefit assessments.^[2]

Overview

Definition and Scope

Immunosuppression refers to a reduction in the activation or efficacy of the immune system, encompassing diminished responses from both innate and adaptive immunity, which normally protect against pathogens and aberrant cells.^[1] This state impairs the body's ability to mount effective defenses, increasing vulnerability to infections, malignancies, and other disorders.^[3] In physiological contexts, immunosuppression contributes to immune homeostasis by preventing excessive inflammation and autoimmunity, as seen in regulatory mechanisms that balance activation and suppression to maintain tissue integrity.^[4] The scope of immunosuppression includes primary forms, which arise from genetic defects present from birth, and secondary forms, which are acquired later due to external factors such as infections, malignancies, or environmental exposures.^[5] Primary immunosuppression stems from intrinsic immune cell abnormalities, like those in severe combined immunodeficiency, while secondary types result from conditions such as HIV infection or malnutrition that compromise immune function over time.^[6] It is further classified into deliberate (iatrogenic) suppression, intentionally induced through medical interventions like drug therapy to manage conditions such as transplant rejection, and non-deliberate (pathological or environmental) suppression, which occurs unintentionally from disease processes or toxins leading to unintended immune compromise.^[7]^[8] Pathological immunosuppression disrupts homeostasis, heightening risks beyond normal regulatory suppression, whereas physiological examples illustrate adaptive balance; for instance, during pregnancy, the maternal immune system undergoes targeted suppression to tolerate the semi-allogeneic fetus without compromising overall defenses against infection.^[9] Clinically, immunosuppression is coded under ICD-10 as D89.9 for unspecified disorders involving the immune mechanism, and it aligns with the MeSH term D007165 for immunosuppression therapy, emphasizing its deliberate applications in medical practice.^[10]^[11]

Historical Development

The development of immunosuppression began in the mid-20th century with the introduction of corticosteroids, such as cortisone, which were first used experimentally in the early 1950s to mitigate transplant rejection. These agents, discovered in the 1940s through adrenal gland research, provided the initial broad-spectrum suppression of immune responses but were limited by significant side effects like infection risk and metabolic disturbances.^[12] A pivotal milestone occurred in 1954 when Joseph E. Murray performed the first successful kidney transplant between identical twins in Boston, without the need for immunosuppressive therapy due to the lack of genetic mismatch, marking the dawn of clinical transplantation immunology.^[12] The 1960s saw further advancements with the synthesis of azathioprine, a purine analog derived from 6-mercaptopurine, introduced in 1960 by Roy Calne and approved for clinical use by 1962; combined with prednisone, it enabled the first successful allografts between non-identical siblings and unrelated donors.^[12] This era shifted immunosuppression from irradiation-based approaches to pharmacological ones, improving graft survival rates from near zero to over 50% in some cases. The 1980s brought a revolution with cyclosporine, a calcineurin inhibitor isolated from fungi in 1970 and clinically applied from 1978 onward, which specifically targeted T-cell activation and dramatically increased one-year kidney transplant success to 80-90%, transforming organ transplantation into a viable therapy.^[12] Tacrolimus, another calcineurin inhibitor, followed in 1989, offering enhanced potency with fewer cosmetic side effects.^[12] In 1990, the Nobel Prize in Physiology or Medicine was awarded to Joseph Murray and E. Donnall Thomas for their pioneering work in organ and bone marrow transplantation, respectively, underscoring the field's maturation. The post-2000 period introduced targeted biologics, exemplified by rituximab, a monoclonal antibody against CD20 approved by the FDA in 1997 for lymphoma but expanded in the 2010s for autoimmune conditions like rheumatoid arthritis (2006 approval) and vasculitis, enabling precise B-cell depletion with reduced systemic toxicity.^[13] Recent developments include Janus kinase (JAK) inhibitors like tofacitinib, FDA-approved in 2012 for rheumatoid arthritis, which gained expanded use in 2021 for managing COVID-19-related hyperinflammation by blocking cytokine signaling, as demonstrated in randomized trials showing reduced mortality and respiratory failure.^[14] This progression reflects a broader shift from non-specific, high-dose regimens to mechanism-specific therapies, minimizing opportunistic infections and long-term complications while broadening applications beyond transplantation.^[15]

Mechanisms

Cellular and Molecular Pathways

Immunosuppression at the cellular level involves the targeted inhibition of innate immune components, such as macrophages and natural killer (NK) cells, primarily through cytokine blockade. Macrophages, key effectors in innate immunity, are suppressed by interrupting pro-inflammatory signaling pathways like those mediated by interleukin-1 (IL-1) and tumor necrosis factor-alpha (TNF-α), which normally drive phagocytosis, cytokine production, and antigen presentation.^[16] Similarly, NK cells exhibit reduced cytotoxicity and interferon-gamma secretion when TNF-α or IL-1 pathways are blocked, limiting their role in early pathogen surveillance and limiting viral spread.^[17] These mechanisms prevent excessive innate responses, maintaining homeostasis without eradicating the cells entirely. In adaptive immunity, suppression occurs through direct modulation of T and B lymphocytes. T-cell activation and proliferation are dampened by the interaction between cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) on T cells and B7 ligands (CD80/CD86) on antigen-presenting cells, which delivers an inhibitory signal that competes with the co-stimulatory CD28-B7 pathway, thereby reducing interleukin-2 production and T-cell expansion.^[18] B-cell function is curtailed via depletion strategies targeting CD20, a surface marker on mature B cells, leading to antibody-dependent cellular cytotoxicity and complement-mediated lysis that diminishes humoral responses.^[19] Additionally, apoptosis induction in activated lymphocytes, often via Fas-FasL signaling or mitochondrial pathways, eliminates effector cells post-response, preventing chronic activation and autoimmunity.^[20] At the molecular level, key signaling cascades are disrupted to enforce immunosuppression. The calcineurin-nuclear factor of activated T cells (NFAT) pathway is blocked when calcineurin, a phosphatase, is inhibited, preventing NFAT dephosphorylation and its subsequent nuclear translocation to transcribe genes for T-cell activation, such as interleukin-2; for instance, cyclosporine binds to cyclophilin, forming a complex that allosterically inhibits calcineurin's activity, thereby halting this cascade.^[21] The mammalian target of rapamycin (mTOR) pathway, which regulates lymphocyte metabolism and differentiation, is suppressed by inhibitors that halt protein synthesis and autophagy, shifting T cells toward anergy or regulatory phenotypes while impairing effector functions in both innate and adaptive cells.^[22] Disruption of Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling, critical for cytokine receptor responses, attenuates downstream gene expression for proliferation and survival in immune cells, effectively dampening responses to interleukins like IL-2 and IL-6.^[23] Physiological immunosuppression relies on feedback loops involving regulatory T cells (Tregs), which express Foxp3 and suppress effector responses through contact-dependent inhibition (e.g., CTLA-4-mediated B7 sequestration) and secretion of anti-inflammatory cytokines like IL-10 and TGF-β, creating a self-limiting circuit that prunes overactive lymphocytes and preserves tolerance.^[24] In pathological contexts, dysregulation of these loops, such as excessive Treg activity or impaired feedback, can amplify suppression, leading to immune evasion or tolerance breakdown, though endogenous mechanisms like IL-2-mediated Treg expansion maintain balance under normal conditions.^[25]

Pharmacological and Non-Pharmacological Methods

Immunosuppressive agents are broadly classified into several pharmacological categories based on their primary mechanisms of action, including corticosteroids, calcineurin inhibitors, antimetabolites, mTOR inhibitors, and biologics. These classes target different aspects of the immune response to achieve suppression, often used in combination to optimize efficacy.^[2] Corticosteroids, such as prednisone, exert immunosuppressive effects by binding to glucocorticoid receptors, leading to inhibition of inflammatory gene transcription and reduced production of pro-inflammatory cytokines like IL-1, IL-6, and TNF-α. Prednisone is typically administered orally at initial doses of 0.5–1 mg/kg/day, with tapering based on clinical needs.^[26] Calcineurin inhibitors, including cyclosporine and tacrolimus, prevent T-cell activation by inhibiting the calcineurin phosphatase, which blocks dephosphorylation and nuclear translocation of NFAT, thereby suppressing IL-2 gene expression. Cyclosporine is dosed at 3–5 mg/kg/day orally, while tacrolimus is given at 0.1–0.2 mg/kg/day, with levels monitored to maintain therapeutic ranges.^[27]^[26] Antimetabolites like azathioprine and mycophenolate mofetil interfere with DNA synthesis in lymphocytes; azathioprine is metabolized to 6-mercaptopurine, which inhibits purine synthesis, and is dosed at 1–3 mg/kg/day, whereas mycophenolate inhibits inosine monophosphate dehydrogenase, selectively affecting T- and B-cell proliferation, at 1–2 g/day.^[2]^[26] mTOR inhibitors, such as sirolimus and everolimus, block the mammalian target of rapamycin pathway, inhibiting lymphocyte proliferation, protein synthesis, and promoting regulatory T-cell expansion while impairing effector T-cell function. Sirolimus is typically dosed at 2–5 mg/day orally, with trough levels maintained at 5–15 ng/mL.^[2] Biologics encompass monoclonal antibodies and fusion proteins that target specific immune components; infliximab, a chimeric anti-TNF-α antibody, neutralizes soluble and membrane-bound TNF-α to reduce inflammation, administered intravenously at 3–5 mg/kg every 4–8 weeks. Belatacept, a fusion protein of CTLA-4 and IgG Fc, blocks CD80/CD86 co-stimulation on antigen-presenting cells, preventing T-cell activation, and is infused at 10 mg/kg initially, then 5 mg/kg monthly.^[28]^[29] Non-pharmacological methods include total body irradiation (TBI), which delivers ionizing radiation to lymphoid tissues to deplete lymphocytes and induce apoptosis, typically at fractionated doses of 12 Gy over several days to achieve profound lymphoablation. Surgical thymectomy involves removal of the thymus gland to eliminate a primary site of T-cell maturation, performed via minimally invasive or open approaches to reduce T-cell production. Plasmapheresis, or therapeutic plasma exchange, removes circulating antibodies and immune complexes by filtering plasma, exchanging 1–1.5 plasma volumes per session over multiple treatments.^[30]^[31]^[32] Immunosuppressive regimens often combine agents for induction and maintenance phases; induction therapy uses high-intensity agents like antithymocyte globulin or high-dose corticosteroids immediately post-procedure to prevent early rejection, while maintenance involves lower doses of calcineurin inhibitors, antimetabolites, and corticosteroids for long-term control. Costimulatory blockers such as belatacept, approved in 2011, inhibit CD28-mediated T-cell activation and are used in select maintenance protocols.^[33] Recent additions include voclosporin for the treatment of lupus nephritis, a next-generation calcineurin inhibitor approved in 2021, dosed at 23.7 mg twice daily, and expanded use of tocilizumab, an anti-IL-6 receptor antibody, in 2021 for managing cytokine release syndromes at 8 mg/kg intravenously.^[34]^[35]^[36]

Deliberate Applications

Organ and Tissue Transplantation

Immunosuppression plays a critical role in organ and tissue transplantation by preventing the recipient's immune system from rejecting the allograft, primarily through targeting T-cell mediated alloimmunity. In solid organ transplantation, such as kidney, liver, and heart procedures, immunosuppressive regimens are tailored to balance rejection prevention with minimizing infection risks. For kidney transplants, which account for the majority of solid organ procedures, standard protocols involve induction therapy with high-dose agents like antithymocyte globulin (ATG) to deplete T cells immediately post-transplant, followed by maintenance therapy combining a calcineurin inhibitor (e.g., tacrolimus), an antimetabolite (e.g., mycophenolate mofetil), and corticosteroids. Similar approaches are used for liver and heart transplants, though liver recipients often receive lower steroid doses due to hepatotoxicity concerns, and heart protocols may incorporate basiliximab for interleukin-2 receptor blockade during induction. These regimens have evolved from early calcineurin inhibitor-based therapies introduced in the 1980s to modern triple-drug maintenance, significantly improving short-term graft survival.^[37]^[15] In hematopoietic stem cell transplantation (HSCT), immunosuppression focuses on preventing graft-versus-host disease (GVHD), where donor T cells attack host tissues, while preserving the graft-versus-leukemia effect. Protocols typically include post-transplant cyclophosphamide (PTCy) for haploidentical or mismatched donors to selectively deplete alloreactive T cells, combined with a calcineurin inhibitor (e.g., tacrolimus) and methotrexate or mycophenolate mofetil for GVHD prophylaxis. For bone marrow transplants in hematologic malignancies, this regimen is administered starting on the day after infusion, with PTCy given on days 3 and 4 post-transplant to mitigate acute GVHD incidence to below 20% in many cohorts. Induction in HSCT differs from solid organ approaches by emphasizing donor-derived immunity preservation, often avoiding long-term high-dose steroids to maintain anti-tumor effects.^[38]^[39] Outcomes in solid organ transplantation have markedly improved with these protocols, with one-year kidney graft survival approximately 95-97% in U.S. centers as of 2023, up from approximately 90% post-2010, driven by refined immunosuppression and donor management. Liver transplant one-year patient survival reaches around 93-96% nationally as of 2023, with top centers exceeding 95%, while heart transplant graft survival is around 91-93% nationally, up to 98% in leading programs. In HSCT, GVHD prophylaxis has lowered severe acute GVHD incidence, contributing to overall one-year survival rates of 60-80% depending on donor match, though chronic GVHD remains a challenge affecting up to 40% of long-term survivors. Chronic allograft nephropathy, characterized by progressive fibrosis due to calcineurin inhibitor toxicity and immune-mediated injury, limits long-term kidney graft half-life to about 15 years despite these advances.^[40]^[41]^[42]^[43]^[44] Recent advancements incorporate pharmacogenomics for personalized dosing, particularly CYP3A5 genotyping to optimize tacrolimus levels, as expressors (e.g., *1 allele carriers) require 1.5-2 times higher doses to achieve therapeutic troughs, reducing early rejection risk by up to 50% in kidney recipients. This approach, guided by Clinical Pharmacogenetics Implementation Consortium recommendations, has become standard in many centers since the 2010s, with prospective trials confirming improved dose accuracy and fewer adverse events. In HSCT, similar genotyping aids tacrolimus adjustment, though implementation lags behind solid organ practices. These strategies underscore a shift toward precision immunosuppression to enhance long-term outcomes while addressing inter-individual variability in drug metabolism.^[45]^[46]^[47]

Autoimmune and Inflammatory Diseases

Immunosuppression plays a central role in managing autoimmune and inflammatory diseases by dampening aberrant immune responses that target self-tissues, thereby reducing inflammation and preventing organ damage. In conditions such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), multiple sclerosis (MS), and inflammatory bowel disease (IBD), immunosuppressive therapies aim to achieve disease control, induce remission, and minimize long-term complications like joint destruction or neurological deficits. These approaches often involve a combination of conventional disease-modifying antirheumatic drugs (DMARDs), biologics, and emerging targeted agents, tailored to disease severity and patient response.^[48] Rheumatoid arthritis, characterized by chronic synovial inflammation leading to joint erosion, is commonly treated with methotrexate as a first-line DMARD, which inhibits folate metabolism and suppresses T-cell activation to reduce proinflammatory cytokine production. Methotrexate monotherapy or in combination with other agents achieves clinical remission in approximately 40-50% of patients, with sustained benefits observed over years when initiated early. Biologics like adalimumab, a tumor necrosis factor (TNF) inhibitor approved by the FDA in 2002, block TNF-alpha to alleviate symptoms and radiographic progression, demonstrating ACR20 response rates of up to 60% in clinical trials when combined with methotrexate. Small-molecule JAK inhibitors, such as baricitinib approved by the FDA in 2018 for moderately to severely active RA, target Janus kinase pathways to interrupt cytokine signaling, showing superior ACR50 responses (around 50%) compared to placebo or adalimumab in patients with inadequate methotrexate response.^[49]^[50]^[51] Systemic lupus erythematosus involves multisystem autoimmunity driven by autoantibodies and immune complex deposition, where immunosuppression targets B-cell hyperactivity and cytokine storms. Rituximab, a monoclonal antibody depleting CD20-positive B cells, has demonstrated efficacy in refractory SLE cases, achieving partial or complete remission in over 70% of patients in meta-analyses of uncontrolled trials, often as a steroid-sparing agent. Post-2020 developments include phase 1/2 trials of CD19-targeted CAR-T cell therapy, which reprogrammed patient T cells to eliminate autoreactive B cells; in one 2022 study of five refractory SLE patients, all achieved drug-free remission within three months, sustained up to 12 months with no relapses, though cytokine release syndrome occurred in some. As of 2025, additional phase 1 data presented at ACR Convergence showed strong and consistent remission in larger cohorts treated with CD19 CAR-T therapies, including immune remodeling and durable responses up to 2 years in some patients. Ongoing trials (e.g., NCT06106906) continue to evaluate this approach's safety and durability in broader cohorts.^[52]^[53]^[54]^[55]^[56] Multiple sclerosis, an inflammatory demyelinating disease of the central nervous system, benefits from immunosuppressive agents that modulate lymphocyte trafficking and depletion to prevent relapses and slow progression. Fingolimod, an sphingosine-1-phosphate receptor modulator approved in 2010, sequesters lymphocytes in lymph nodes to reduce CNS infiltration, achieving annualized relapse rates of 0.18 in pivotal trials compared to 0.40 with placebo. Ocrelizumab, an anti-CD20 monoclonal antibody approved in 2017, depletes B cells to suppress inflammatory cascades, reducing relapse risk by 46-47% and disability progression by 40% over two years in phase 3 studies. These therapies are particularly effective in relapsing-remitting MS, with combination strategies enhancing outcomes in aggressive disease.^[57]^[58] Inflammatory bowel disease, encompassing Crohn's disease and ulcerative colitis, features gut mucosal inflammation from dysregulated T-cell responses, managed through stepwise immunosuppression to induce and maintain mucosal healing. Azathioprine and its metabolite 6-mercaptopurine, purine analogs inhibiting DNA synthesis in rapidly dividing immune cells, promote steroid-free remission in 40-60% of patients as maintenance therapy after induction. Methotrexate, used primarily in Crohn's disease, stabilizes disease in up to 50% of steroid-dependent cases by reducing Th1 cytokine production, with subcutaneous administration preferred for better bioavailability. Therapeutic protocols often follow a step-up approach, starting with corticosteroids for acute flares to induce remission, escalating to conventional DMARDs like azathioprine or methotrexate for maintenance, and advancing to targeted biologics if inadequate response occurs, aiming for endoscopic remission within 6-12 months.^[59]^[60]^[61] Across these diseases, treatment protocols emphasize remission induction followed by maintenance, with early aggressive immunosuppression improving long-term prognosis; for instance, treat-to-target strategies in RA and IBD monitor disease activity every 3-6 months to adjust therapies, reducing progression risks by 30-50% compared to symptom-driven care.^[62]^[63]

Other Therapeutic Contexts

Immunosuppression plays a role in allergy desensitization through targeted immune modulation during allergen-specific immunotherapy (AIT), which induces tolerance by enhancing regulatory T cells (Tregs) and B cells (Bregs) that suppress allergen-specific effector responses, including IgE production and Th2-mediated inflammation.^[64] This approach, often administered via subcutaneous or sublingual routes, temporarily desensitizes mast cells and basophils to reduce immediate hypersensitivity reactions, representing a short-term suppressive strategy rather than broad systemic immunosuppression.^[65] In dermatological conditions such as psoriasis, biologic agents like ustekinumab, a monoclonal antibody targeting IL-12 and IL-23, exert immunosuppressive effects by inhibiting pro-inflammatory cytokine signaling, thereby reducing T-cell activation and keratinocyte proliferation in psoriatic plaques.^[66] Approved for moderate-to-severe plaque psoriasis, ustekinumab is typically used in chronic regimens but carries risks of increased infections due to its modulation of adaptive immunity.^[67] Similarly, for organ-specific inflammations like uveitis, systemic immunosuppressants such as antimetabolites (e.g., methotrexate or mycophenolate mofetil) and calcineurin inhibitors are employed to control intraocular inflammation while minimizing steroid dependence, often in combination protocols tailored to disease severity.^[68] Specialized applications include pregnancy-related fetal-maternal conflicts, where intravenous immunoglobulin (IVIG) serves as an immunomodulator to suppress alloimmune responses in conditions like recurrent miscarriage or hemolytic disease of the fetus and newborn, improving live birth rates without broad immunosuppressive toxicity.^[69] In gene therapy, preconditioning with lymphodepleting agents or myeloablative chemotherapy temporarily suppresses host immunity to enhance vector engraftment and reduce anti-vector immune responses, as seen in adeno-associated virus (AAV)-based therapies for inherited disorders.^[70] Emerging uses encompass neuroinflammatory diseases beyond standard autoimmune contexts. In xenotransplantation trials post-2020, such as the March 2024 porcine kidney transplant into a human recipient at Massachusetts General Hospital, which functioned for over 13 months before removal due to an unrelated infection, and a second transplant in February 2025, intensified immunosuppression regimens—including antithymocyte globulin induction, rituximab, tacrolimus, mycophenolate mofetil, and prednisone—have enabled short-term graft function despite hyperacute rejection risks. As of 2025, FDA-approved clinical trials for gene-edited pig kidney transplants are underway, marking further progress.^[71]^[72]^[73] Protocols in these contexts vary between short-term applications, such as desensitization phases in AIT or preconditioning for gene therapy, which aim for transient immune suppression to achieve tolerance or engraftment with minimal long-term exposure, and chronic regimens for conditions like psoriasis or uveitis, where ongoing low-dose combinations with non-immunosuppressants (e.g., topical therapies) balance efficacy and toxicity.^[74] These tailored approaches prioritize steroid-sparing strategies to mitigate cumulative risks while leveraging agent-specific mechanisms.^[75]

Non-Deliberate Causes

Infectious and Post-Infectious States

Immunosuppression can arise directly from active infections where pathogens interfere with host immune function. In human immunodeficiency virus (HIV) infection, progressive depletion of CD4+ T cells occurs primarily through apoptosis of infected and uninfected cells, as well as pyroptosis triggered by abortive infection in resting CD4+ T cells.^[76]^[77] This depletion is exacerbated by the virus's ability to integrate its genetic material into the host genome via the integrase enzyme, establishing a persistent provirus that evades immune clearance and promotes chronic inflammation.^[78] Hepatitis B virus (HBV) and hepatitis C virus (HCV) contribute to immunosuppression through chronic infection that induces T-cell exhaustion and impairs antiviral immune responses, particularly via sustained elevation of regulatory T cells and cytokine dysregulation.^[79] Parasitic infections, such as malaria caused by Plasmodium falciparum, induce immunosuppression by manipulating host innate immune responses, including the suppression of proinflammatory cytokine production and promotion of regulatory monocytes that dampen T-cell activation.^[80] These infectious processes often involve mechanisms like cytokine storms, where excessive release of proinflammatory cytokines such as interleukins and interferons leads to immune cell hyperactivation followed by exhaustion, particularly in T cells, reducing their proliferative and effector functions.^[81]^[82] In severe cases, this exhaustion manifests as diminished cytokine secretion and upregulation of inhibitory receptors on T cells, allowing pathogen persistence.^[83] Post-infectious states extend these effects beyond acute resolution, as seen in long COVID, where persistent T-cell exhaustion and immune dysregulation affect a subset of individuals following SARS-CoV-2 infection. Studies from 2021 to 2025 indicate that 6.6% to 10.4% of infected individuals experience prolonged symptoms linked to T-cell hyperactivation and exhaustion, with altered distributions of T-cell subsets and elevated markers like PD-1.^[84]^[85] This dysregulation increases vulnerability to secondary bacterial infections, with incidences reported at 6% to 8.1% among hospitalized COVID-19 patients, often involving pathogens like Acinetobacter and Klebsiella due to impaired antibacterial immunity.^[86]^[87] Similarly, Epstein-Barr virus (EBV) infection can lead to lymphoproliferative disorders in the context of post-infectious immune compromise, where EBV-driven B-cell proliferation exploits residual T-cell dysfunction, resulting in uncontrolled lymphoid expansion.^[88]

Malignancies and Oncologic Treatments

Immunosuppression in malignancies arises from both the direct effects of the tumor and the therapies employed to treat it, compromising the patient's immune surveillance and increasing vulnerability to secondary complications. In hematologic malignancies such as leukemia, tumor cells infiltrate the bone marrow, displacing normal hematopoietic progenitors and leading to profound myelosuppression that impairs the production of neutrophils, lymphocytes, and other immune cells.^[89] This bone marrow suppression is a hallmark of acute leukemias, where leukemic blasts overwhelm the microenvironment, resulting in anemia, thrombocytopenia, and neutropenia that collectively weaken innate and adaptive immunity.^[90] Myeloid-derived suppressor cells (MDSCs), often expanded in the tumor microenvironment of these malignancies, further exacerbate immunosuppression by inhibiting T-cell activation and proliferation through mechanisms like arginase-1 production and reactive oxygen species.^[91] Solid tumors contribute to immunosuppression via systemic effects such as cachexia and paraneoplastic syndromes, which disrupt metabolic homeostasis and immune regulation. Cancer-associated cachexia, prevalent in advanced solid tumors like lung and pancreatic cancer, involves chronic inflammation driven by tumor-derived cytokines (e.g., IL-6, TNF-α), leading to skeletal muscle wasting, adipose depletion, and altered immune cell function, including reduced T-cell responses and increased regulatory T cells.^[92] Paraneoplastic syndromes, such as those seen in small cell lung cancer, arise from ectopic hormone production or autoimmune cross-reactivity, causing immune dysregulation that manifests as neuropathy or hypercalcemia, indirectly suppressing effective antitumor immunity.^[93] These tumor-induced states create a permissive environment for disease progression by dampening host defenses.^[94] Oncologic treatments amplify immunosuppression through direct cytotoxicity to immune cells. Chemotherapy with alkylating agents like cyclophosphamide targets rapidly dividing cells, including bone marrow precursors, resulting in dose-dependent myelosuppression and lymphopenia that persists for weeks post-treatment.^[95] Radiation therapy, while localized, induces systemic lymphopenia by depleting circulating lymphocytes and promoting immunosuppressive factors like TGF-β in the tumor microenvironment, with effects lasting months depending on dose and field.^[96] Paradoxically, immune checkpoint inhibitors (e.g., anti-PD-1/PD-L1 antibodies) enhance antitumor immunity but can trigger immune-related adverse events (irAEs), such as colitis or endocrinopathies, necessitating immunosuppressive interventions like corticosteroids to manage hyperactive immune responses.^[97] These immunosuppressive effects culminate in heightened susceptibility to opportunistic infections, particularly during periods of neutropenia following chemotherapy, where bacterial pathogens like Pseudomonas aeruginosa or fungal agents such as Aspergillus predominate due to impaired phagocytosis and barrier defenses.^[98] In recent advancements, chimeric antigen receptor T-cell (CAR-T) therapies, first approved by the FDA in 2017 for refractory B-cell malignancies (e.g., tisagenlecleucel for pediatric acute lymphoblastic leukemia), elicit potent cytokine release syndrome (CRS) as a side effect, characterized by IL-6-driven inflammation that requires transient immunosuppression with agents like tocilizumab to prevent life-threatening complications.^[99] This managed immunosuppression balances therapeutic efficacy against acute toxicity risks.^[100]

Nutritional, Environmental, and Genetic Factors

Protein-calorie malnutrition, a condition characterized by insufficient intake of proteins and calories, severely compromises the immune system by impairing both humoral and cell-mediated immunity, leading to increased susceptibility to infections. This form of malnutrition disrupts lymphocyte production and function, reduces antibody responses, and weakens phagocytic activity in macrophages and neutrophils.^[101] Micronutrient deficiencies further exacerbate immunosuppression; for instance, zinc deficiency hinders T-cell maturation, differentiation, and proliferation by reducing thymulin activity—a zinc-dependent hormone essential for T-cell development—and decreasing interleukin-2 production, resulting in lymphopenia and a shift toward Th2-dominant responses over protective Th1 immunity.^[102] Similarly, vitamin D deficiency skews T-cell differentiation toward pro-inflammatory Th1 and Th17 phenotypes while reducing regulatory T-cell induction, thereby promoting chronic inflammation and heightened infection risk.^[103] Environmental exposures to toxins also induce immunosuppression through diverse mechanisms. Heavy metals such as lead disrupt T- and B-cell responses and cytokine production, impairing overall immune efficacy, while mercury triggers oxidative stress that alters macrophage function and antibody synthesis.^[104] Pesticides, including atrazine and chlordane, alter lymphocyte proliferative responses and natural killer cell activity, as evidenced in rodent models of perinatal exposure, potentially increasing vulnerability to infections in developing organisms.^[105] Chronic stress contributes via sustained elevation of cortisol, a glucocorticoid that suppresses immune responses by inhibiting cytokine release and lymphocyte activity, thereby diminishing the body's ability to mount effective defenses.^[106] Genetic factors underlie primary immunodeficiencies that cause profound immunosuppression from birth. Severe combined immunodeficiency (SCID) results from genetic defects in genes like those encoding the interleukin-2 receptor or RAG1/RAG2, leading to absent or dysfunctional T- and B-cells and severe susceptibility to opportunistic infections.^[6] DiGeorge syndrome, caused by a 22q11 deletion affecting thymic development, produces variable T-cell deficiencies that impair defenses against viral and fungal pathogens.^[6] Ataxia-telangiectasia, an autosomal recessive disorder due to mutations in DNA repair genes on chromosome 11, features reduced T-cell numbers and function alongside low immunoglobulin levels, elevating risks of recurrent infections and malignancies.^[6] These factors often interact cumulatively, as seen in aging-related immunosenescence, where progressive decline in immune competence—marked by thymic involution, reduced naive T-cell production, and chronic low-grade inflammation—amplifies the immunosuppressive effects of nutritional deficits or environmental insults, heightening overall infection vulnerability in older adults.^[107]

Risks and Complications

Infectious and Oncologic Risks

Immunosuppression significantly heightens susceptibility to opportunistic infections, where pathogens that are typically harmless in immunocompetent individuals can cause severe disease. Common examples include Pneumocystis jirovecii pneumonia (PJP), a fungal infection primarily affecting the lungs, and cytomegalovirus (CMV) infection, a herpesvirus that can lead to pneumonitis, retinitis, or gastrointestinal involvement. These infections are particularly prevalent in transplant recipients and patients with hematologic malignancies or those on high-dose glucocorticoids, as impaired T-cell immunity fails to control pathogen proliferation. In renal transplant patients, co-infection with PJP and CMV occurs in up to 46% of PJP cases, resulting in markedly elevated inflammatory markers and prolonged recovery times compared to PJP alone.^[108]^[109] Prophylaxis plays a critical role in mitigating these infectious risks, with trimethoprim-sulfamethoxazole (TMP-SMX) serving as the first-line agent for preventing PJP in solid organ transplant recipients. Guidelines recommend TMP-SMX at a dose of 80/400 mg daily for at least 6-12 months post-transplant, which has been shown to effectively eliminate PJP incidence in kidney transplant cohorts without breakthrough cases, even when dose reductions are required for side effects like hyperkalemia or leukopenia. This approach underscores the balance between infection prevention and managing drug toxicities in immunosuppressed populations.^[110]^[111]^[112] On the oncologic front, immunosuppression elevates malignancy risk by impairing immune surveillance against nascent tumors and oncogenic viruses. Post-transplant lymphoproliferative disorder (PTLD), often driven by Epstein-Barr virus (EBV) in the context of cumulative immunosuppressive burden, presents a spectrum from benign lymphoid hyperplasia to aggressive lymphoma, with higher incidence linked to high-dose calcineurin inhibitors and antimetabolites. Similarly, azathioprine exposure in organ transplant recipients is associated with a 56% increased risk of squamous cell carcinoma, the most common skin cancer in this group, due to its interference with DNA repair and enhanced UV sensitivity.^[113]^[114]^[115] Quantified risks highlight the scale of these vulnerabilities: bacterial infections affect 59-68% of liver transplant recipients, far exceeding general population rates and contributing to 13-21% of post-transplant deaths across organ types. In HIV-induced immunosuppression, human papillomavirus (HPV)-related cancers, such as anal and cervical carcinomas, carry a threefold higher incidence compared to the general population, exacerbated by persistent viral replication. Data from 2023 reveal disproportionate COVID-19 impacts, with immunocompromised individuals comprising 4% of the studied population yet accounting for approximately 22% of hospitalizations and deaths, indicating an approximately twofold elevated risk for severe outcomes relative to immunocompetent peers. As of 2025, immunocompromised individuals remain at increased risk for severe COVID-19 despite vaccination, with guidelines recommending additional doses of updated vaccines.^[116]^[117]^[118]^[119]

Organ and Systemic Toxicity

Immunosuppressive agents, while essential for preventing graft rejection and managing autoimmune conditions, are associated with significant organ-specific toxicities that can impair renal, hepatic, and skeletal function. Cyclosporine, a calcineurin inhibitor, induces nephrotoxicity through acute vasoconstriction of renal arterioles, leading to reduced glomerular filtration rate and, in chronic cases, afferent arteriolopathy and interstitial fibrosis.^[120] This effect is dose-dependent and exacerbated by concurrent nephrotoxic drugs like aminoglycosides.^[121] Similarly, azathioprine, a purine analog, causes hepatotoxicity in up to 10% of patients, manifesting as elevated transaminases, cholestasis, or nodular regenerative hyperplasia, often idiosyncratic and reversible upon discontinuation.^[122] Glucocorticoids, such as prednisone, contribute to osteoporosis by inhibiting osteoblast function and promoting osteoclast activity, resulting in rapid bone loss of 4-10% in the lumbar spine within the first 6-18 months post-transplantation.^[123]^[124] Systemic toxicities extend beyond individual organs, affecting metabolic and cardiovascular homeostasis. Glucocorticoids frequently induce hyperglycemia and new-onset diabetes mellitus by impairing insulin sensitivity and beta-cell function, with risks increasing with doses exceeding 5 mg/day of prednisone equivalent, affecting up to 32% of non-diabetic patients after one month of therapy.^[125] Calcineurin inhibitors like tacrolimus and cyclosporine promote hypertension through renal sodium retention via activation of the distal tubule's sodium-chloride cotransporter and endothelial dysfunction, occurring in 50-80% of transplant recipients.^[126]^[127] These effects compound over time, elevating long-term cardiovascular morbidity. In pediatric populations, prolonged immunosuppressive therapy poses unique long-term risks, including growth retardation primarily driven by glucocorticoids, which suppress growth hormone secretion and linear bone growth, leading to height standard deviation scores below -2 in up to 40% of renal transplant children.^[128] Infertility risks vary by agent; alkylating agents like cyclophosphamide carry high gonadal toxicity, causing azoospermia in 60-90% of males and premature ovarian failure in females, while calcineurin inhibitors and azathioprine pose lower but notable risks through direct germ cell damage or hormonal disruption.^[129] These outcomes underscore the need for tailored regimens in reproductive-age patients. Monitoring for toxicities relies on targeted biomarkers to enable early intervention. Serum creatinine levels serve as a primary indicator of nephrotoxicity from calcineurin inhibitors, with rises above 30% from baseline prompting dose adjustment.^[130] For BK polyomavirus-associated nephropathy, a complication linked to over-immunosuppression, quantitative PCR assays for BK virus in plasma or urine are recommended monthly in the first year post-transplant, with viral loads exceeding 10,000 copies/mL signaling high risk.^[131] Regular dual-energy X-ray absorptiometry scans assess glucocorticoid-induced bone density loss, guiding bisphosphonate prophylaxis in at-risk patients.^[132]

Management Strategies

Monitoring and Prevention

Monitoring immunosuppressive therapy involves regular assessment of drug concentrations and immune status to optimize efficacy and minimize toxicity. Therapeutic drug monitoring (TDM) is essential for agents like tacrolimus, where trough levels are typically targeted between 5-15 ng/mL to prevent rejection while avoiding nephrotoxicity.^[133] This range may vary by patient factors such as time post-transplant and organ type, with levels often adjusted based on clinical response and side effects.^[134] Immune function assays, including flow cytometry to quantify lymphocyte subsets like CD4+ T cells, provide insights into the degree of immunosuppression and help detect over- or under-suppression.^[135] These assays are particularly useful in serial monitoring to correlate immune reconstitution with infection risk or graft outcomes.^[136] Preventive strategies focus on mitigating infection and malignancy risks inherent to immunosuppression. Vaccination protocols recommend inactivated vaccines for routine protection, while live vaccines such as measles-mumps-rubella or varicella are contraindicated due to the potential for disseminated disease in immunocompromised individuals.^[137] Antimicrobial prophylaxis, including trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia and antiviral agents like acyclovir for herpesviruses, is standard in the early post-transplant period to reduce opportunistic infections.^[138] Lifestyle measures, such as consistent sun protection with broad-spectrum sunscreen (SPF 30+), protective clothing, and avoiding peak UV hours, are critical to lower the elevated skin cancer risk in immunosuppressed patients.^[139] Advanced tools enhance personalized monitoring and prevention. Pharmacogenomic testing identifies genetic variants affecting drug metabolism, such as CYP3A5 polymorphisms influencing tacrolimus dosing, enabling tailored regimens to improve adherence and reduce adverse events.^[140] Emerging AI-driven predictive models, developed post-2020, analyze patient data including drug levels and biomarkers to forecast rejection or infection risks, supporting proactive dose adjustments in transplant care.^[141] To address monitoring gaps exposed by the COVID-19 pandemic, telemedicine has been incorporated into guidelines for immunosuppressed patients, facilitating remote assessment of symptoms and vital signs while reducing clinic visits and exposure risks, with protocols updated in 2023 to emphasize hybrid care models.^[142]

Reversal and Long-Term Care

Reversal of immunosuppression involves carefully managed protocols to gradually restore immune function while minimizing risks such as graft rejection or disease recurrence. In organ transplantation, steroid tapering is a common approach, often involving an initial rapid reduction followed by slower decrements over several months to avoid abrupt withdrawal effects; for instance, in kidney transplant recipients, early steroid withdrawal within 3-6 months post-transplant has been successfully implemented in protocols using alternative immunosuppressants like tacrolimus and mycophenolate mofetil, reducing side effects without significantly increasing acute rejection rates.^[143] Switching to less toxic agents, such as from calcineurin inhibitors to mammalian target of rapamycin inhibitors like sirolimus, further supports reversal by maintaining efficacy while alleviating long-term toxicities like nephrotoxicity.^[144] Challenges in reversal include the potential for rebound autoimmunity upon withdrawal, where discontinuing immunosuppression can trigger recurrence of underlying autoimmune conditions or heightened immune responses against the graft; studies in pancreas transplantation have documented islet autoimmunity resurgence despite ongoing therapy, highlighting the need for vigilant monitoring during taper.^[145] In transplants, achieving immune tolerance—where the recipient's immune system accepts the donor organ without continuous drugs—remains elusive but is pursued through strategies like combined thymus and organ transplantation from the same donor to promote donor-specific tolerance via central mechanisms.^[146] Cellular approaches, including adoptive transfer of regulatory T cells, show promise in inducing peripheral tolerance but face barriers like off-the-shelf cell stability and scalability.^[147] Long-term care for patients post-reversal emphasizes multidisciplinary teams involving transplant specialists, oncologists, and infectious disease experts to address ongoing vulnerabilities. Annual cancer screening is recommended, particularly for skin, renal, and lymphoproliferative malignancies, given the elevated risk from prior immunosuppression; for example, guidelines advocate annual dermatologic exams for solid organ recipients to detect keratinocyte carcinomas early.^[148] Patient education plays a critical role, instructing individuals to recognize infection signs such as persistent fever, unexplained fatigue, or skin changes, and to adhere to preventive measures like vaccinations and hygiene to mitigate recurrent risks.^[149] Recent advancements include stem cell therapies for immune reconstitution, particularly in HIV, where allogeneic hematopoietic stem cell transplantation (allo-HSCT) has achieved sustained remission in multiple cases during the 2020s. As of 2025, ten individuals have been reported cured of HIV following allo-HSCT for malignancies, with donor cells lacking the CCR5 receptor enabling viral clearance and immune recovery without antiretroviral therapy; ongoing trials explore broader applications, such as umbilical cord blood transplants, to enhance accessibility.^[150]^[151]^[152]

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Safety and efficacy of prophylaxis for Pneumocystis jirovecii ...
Apr 5, 2019 · Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for anti-Pneumocystis jirovecii pneumonia (PcP) prophylaxis in kidney transplant recipients (KTR).
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European best practice guidelines for renal transplantation. Section IV
All renal transplant recipients should receive PCP prophylaxis. The treatment of choice is trimethoprim-sulfamethoxazole (TMP-SMX), at a dose of 80/400 mg/day.
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Posttransplant Lymphoproliferative Disorders - StatPearls - NCBI - NIH
High-dose immunosuppression is associated with a higher risk of PTLD. The clinical presentation of PTLD can be highly variable ranging from localized to ...Continuing Education Activity · Introduction · Evaluation · Treatment / Management
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Two main risk factors of PTLD are: Firstly, the cumulative immunosuppressive burden, and secondly, the oncogenic impact of the Epstein-Barr virus. The latter ...
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Azathioprine and Risk of Skin Cancer in Organ Transplant Recipients
The overall summary estimate showed a significantly increased risk of SCC in relation to azathioprine exposure (1.56, 95% confidence interval [CI] 1.11-2.18).
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Infections in Solid-Organ Transplant Recipients - PMC
Bacterial infections occur in 59% to 68% of the patients after liver transplantation. About half of these infections occur within 2 weeks after transplant. The ...
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Oct 8, 2024 · Our study found that PLWH have a roughly three-fold increased risk of developing HPV-associated cancers compared to the general population. This ...Introduction · Methods · Results · Discussion
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Influence of cyclosporine on the occurrence of nephrotoxicity after ...
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Bone Loss after Solid Organ Transplantation
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May 29, 2017 · Glucocorticoid-induced diabetes mellitus (GIDM) is a common and potentially harmful problem in clinical practice, affecting almost all medical specialties.
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Fresh insights into glucocorticoid-induced diabetes mellitus and new ...
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Calcineurin inhibitor effects on kidney electrolyte handling and ...
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Immunosuppressive Therapy, Puberty and Growth Outcomes in ...
Oct 24, 2024 · Immunosuppressive therapy can have significant side effects specific to pediatric patients, such as adverse impacts on physiological growth, puberty, and ...
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Immunosuppressive drugs and fertility - PMC - PubMed Central - NIH
Oct 21, 2015 · ... drug, imperatively in relation with the prescriber of the immunosuppressive drugs. ... drugs but this risk can now be anticipated. Clinical ...
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Jan 29, 2025 · Post-transplant osteoporosis and fracture occur in a substantial proportion of patients. The pathogenesis, clinical manifestations, and ...
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Higher tacrolimus trough levels and time in the therapeutic range ...
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The Evolution of Therapeutic Drug Monitoring for Tacrolimus
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TBNK - Overview: Quantitative Lymphocyte Subsets: T, B, and NK ...
Serial monitoring of CD4 T-cell count in HIV-positive patients. Follow-up and diagnostic evaluation of primary immunodeficiencies, including severe combined ...
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Prophylaxis of infections in solid organ transplantation - UpToDate
INTRODUCTION. Immunosuppressed solid organ transplant recipients are at "high risk" for developing infection; invasive infection progresses rapidly in these ...
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Skin Cancer Prevention - StatPearls - NCBI Bookshelf
Further, a general decrease in immunosuppression by making the previous changes or lower the use of steroids can also decrease the risk of skin cancer.
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Advancing Immunosuppressive Therapy in Solid Organ ...
Jun 6, 2025 · This webinar will explore the critical role of pharmacogenomics and therapeutic drug monitoring (TDM) in managing immunosuppressive therapy for solid organ ...
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AI-Driven Tacrolimus Dosing in Transplant Care: Cohort Study
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Telehealth Experience Among Liver and Kidney Transplant Recipients
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The goal of steroid minimization protocols has been to eliminate or minimize steroid-related side effects while not increasing the rates of acute rejection (AR) ...
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Impact of Single Immunosuppressive Drug Withdrawal on ...
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Recurrence of Autoimmunity Following Pancreas Transplantation
Other studies contributed evidence that recurrence of islet autoimmunity can occur regardless of HLA sharing (8) and despite immunosuppression (9–11), and can ...
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Tolerance Induction Strategies in Organ Transplantation
Oct 7, 2025 · Combining thymus and organ transplantation from the same donor represents a potent strategy to induce immune tolerance.
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Cellular strategies to induce immune tolerance after liver ...
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Skin cancer screening after solid organ transplantation: Survey of ...
Jan 2, 2019 · Guidelines recommend annual dermatology screening after solid organ transplantation to facilitate early detection of keratinocyte carcinoma ...<|separator|>
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Discharge Instructions for Immunocompromised Patients
The following information will help you protect yourself from infection. Medicine, Skin care, FOOD, Keep your home clean, Prevent colds and the flu.Skin Care · Other Ways To Lower Your... · When To Call Your Healthcare...
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Sustained HIV remission after allogeneic hematopoietic stem cell ...
Sep 2, 2024 · HIV cure has been reported for five individuals who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) with cells from ...
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Deep Thought on the HIV Cured Cases: Where Have We Been and ...
Mar 5, 2025 · To date, there have been a total of seven cured cases of HIV worldwide. These patients all cleared HIV while undergoing allogeneic stem cell ...