Corticosteroids are converted to an appropriate dosage form using methylprednisone (5 mg for each 1 mg of hydrocortisone) or hydrocortisone (4 mg for each 1 mg of prednisone) when intravenous administration is required.

Because most posttransplant immunosuppression includes administration of chronic corticosteroids, when transplant recipients develop emergent problems requiring surgical intervention (e.g., perforated ulcer, motor vehicle accident. etc.) or even for a planned operation (e.g., herniorraphy), the physiologic response to stress must be considered. Accordingly, it is important to consider corticosteroid management as an integral component of the care algorithm. Although the penalty associated with temporary administration of "stress" corticosteroids is relatively small, available evidence suggests this is not usually necessary. Transplant recipients receiving > 10 mg/day, prednisone rarely require additional steroids to accommodate acute stress.1 Occasionally, individuals receiving lower doses require additional corticosteroid dosing. We generally treat patients who experience highly stressful circumstances (e.g., hypotension, septic shock, coronary bypass surgery) with hydrocortisone, 100 mg, every 8 hours during maximal stress with a rapid taper to maintenance when the stressful situation subsides (usually 3-5 days). It is also important to recognize that the diagnosis of "stress" is highly subjective; the clinician must have familiarity with the signs and symptoms of adrenal insufficiency (Table E9.2). Whenever a patient presents a clinical setting with consistent clinical signs or symptoms, such as unexplained hypotension or hyperkalemia, adrenal insufficiency should be prominently considered in the differential diagnosis. Rapid resolution after an initial intravenous dose of hydrocortisone, 100 mg, can be considered diagnostic in such a setting.

Withholding Immunosuppression

In life threatening circumstances it is occasionally important to temporarily discontinue immunosuppression, hoping to permit resolution of an acute medical problem. For example, profound sepsis failing to respond to usual measures, when posing an immediate threat to survival, may justify cessation of transplant related immunosuppressants. When such a decision is made, the clinical course must be closely observed. Immunosuppression should be resumed concomitant with early clinical recovery to avoid acute allograft rejection. Decision making in situations such as this becomes quite difficult, because specific therapeutic guidelines are remarkably elusive. Rather, highly subjective clinical judgement is extremely important, particularly when considering reintroduction of immunosuppression.

Similar clinical judgement is also required during administration of chemotherapy in treatment of malignancy. We have discontinued immunosuppression for prolonged periods on several occasions with successful control of the underlying process and without compromise to allograft function. Again, timing becomes critical when considering the reintroduction of immunosuppression.

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