Predictive Power of Self-Efficacy on the Fear of Childbirth in Pregnant Women: Underlying Mechanisms of Social Support as a Mediator and the COVID-19 Fear as a Moderator.

BACKGROUND: Fear of childbirth (FOC) is a common problem associated with psycho-social factors in pregnant women. OBJECTIVES: This study aimed to determine the mediator of social support and the moderator role of fear of coronavirus disease 2019 (COVID-19) in the relationship between self-efficacy and FOC in pregnant women. MATERIALS AND METHODS: This descriptive and cross-sectional study was conducted with 422 pregnant women registered in 18 family health centers. Data were collected with the introductory information form, the Wijma Delivery Expectancy/Experience Questionnaire-A, the Childbirth Self-Efficacy Inventory, the Multidimensional Scale of Perceived Social Support, and the Fear of COVID19 Scale. The SPSS 22 package program and Hayes's process macro 3.2 were used in the analysis of the data. RESULTS: Findings showed that 19.9% of the pregnant women experienced severe FOC. Self-efficacy and social support negatively predicted FOC, while fear of COVID-19 predicted it positively. Perceived social support moderately mediated the relationship between FOC and self-efficacy. Fear of COVID-19 was found to be a marginally effective moderator in the relationship between self-efficacy and FOC. This indicates that as self-efficacy increases in pregnant women with low fear of COVID-19, the FOC is experienced less. CONCLUSION: In the relationship between self-efficacy and FOC, social support is a key factor in reducing FOC. To reduce the FOC, the social support of pregnant women should be strengthened, and the fear associated with acute crisis periods such as pandemics should be reduced with some preventive measures.

Mortality in magnet hospitals: A systematic review.

Magnet hospitals are recognized for quality patient outcomes and nursing excellence. It was aimed to examine the effects of Magnet hospitals on mortality rate. Searches for this review were carried out using the PubMed, Scopus, and CINAHL databases without any year limitation. Search terms included Magnet hospitals, non-Magnet hospitals, and mortality. Inclusion criteria were: The identified 58 articles published in international journals, and 13 of those articles that met the inclusion criteria were included in this review. This systematic review adhered to the PRISMA guideline. Articles meeting the research criteria were evaluated for methodological quality with the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) Critical Appraisal Tool. The research types used of the included studies were descriptive comparative research (n = 8), cohort study (n = 4), and retrospective, two-stage panel design (n = 1). Three descriptive comparative studies found that there was no difference in the mortality rates of Magnet hospitals and non-Magnet hospitals. By contrast, five descriptive comparative studies and five longitudinal studies determined that mortality rates were lower in Magnet hospitals. Overall, the findings of this systematic review indicated that Magnet hospitals are associated with lower rates of mortality. Considering the organizational consequences of mortality such as quality and cost savings, this systematic review provides significant contributions to hospital executives, as well as the nurse-clinicians, whether or not to obtain magnet status.

The prevalence of non-vascular pulmonary manifestations in Takayasu's Arteritis patients: A Retrospective multi-centred Turkish cohort study.

OBJECTIVES: Takayasu's arteritis (TAK) is a rare vasculitis characterized by inflammation of intermediate- to large-size arteries. Although pulmonary artery involvement (PAI) is an expected finding in some TAK patients, data on non-vascular pulmonary involvement (NVPI) are limited. We aimed to investigate the frequency of NVPI, including parenchymal infiltration, nodules/cavities, pleural effusion, and haemorrhage, in TAK. METHOD: We assembled a retrospective cohort of TAK patients from nine tertiary centres in Turkey. The demographics and clinical characteristics of patients were extracted from medical records and the imaging findings were evaluated for pulmonary manifestations. RESULTS: As of January 2021, 319 TAK patients (female/male 276/43; mean age 42.4 ± 13.5 years) were recruited. Eighty-two patients had cough and/or dyspnoea and four had haemoptysis as pulmonary symptoms. On computed tomography assessment, the overall frequency of NVPI was 7.2%; parenchymal infiltrations were present in 10 (3.1%), pleural effusion in eight (2.5%), nodules/cavities in six (1.9%), and pulmonary haemorrhage in four patients (1.3%). In the whole cohort, 10.3% of patients had pulmonary artery hypertension (PAH) and 5.6% had PAI. Among patients with PAH or PAI, the overall frequency of NVPI was significantly higher than in the rest of the group. CONCLUSIONS: In this TAK cohort from Turkey, we observed NVPI in 7.2% of patients, with parenchymal infiltrations being the most common, followed by pleural effusion. Notably, NVPI was more frequent in patients with PAH or PAI. Although not as common as PAI, NVPI should be kept in mind, especially in TAK patients with PAH or PAI.

Assessment of internet usage for health-related information among clients utilizing primary health care services.

OBJECTIVE: This study aimed to identify the frequency and goals of Internet usage to access health-related information among primary health care service clients. METHODS: The study was conducted in a primary health care centre with a sample of 788 adults. The data were collected through a questionnaire developed by the researchers. RESULTS: The results showed that 81% (n = 640) of the participants used the Internet. All Internet user participants reported that they used the Internet to access health-related information. Of the participants, 67% reported that they used the Internet primarily to obtain information about diseases with 94% reporting that they found the online information reliable and 92% reported that they did not confirm the information they obtained online. The frequency of Internet use to obtain health-related information increased with increase in the level of education of participants. Participants with higher education found the online information to be more reliable and comprehensible. The results showed that while the use of Internet to obtain health-related information was high, the information presented online was not always checked for accuracy. CONCLUSION: Hence, provision of current and evidence-based information on health-related websites is crucial to preserve community health care.

The usefulness of trauma scores in determining the life threatening condition of trauma victims for writing medical-legal reports.

OBJECTIVES: In the Turkish legal system the severity of the victim's injury determines the severity of the criminal penalty, and the life threatening condition stated in the medical-legal report is one of the main determinants for injury severity. The aim of this study is to investigate the effectiveness and usefulness of the trauma scores in determining the life threatening condition of trauma victims from the forensic aspect in order to write accurate medical-legal reports. METHODS: Data of 296 forensic cases with blunt and penetrating trauma were obtained. The life threatening condition of patients stated in the medical-legal reports according to the criteria based on traditional forensic opinion were examined. For each case, Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS) were calculated. The ROC curve analysis was used to investigate the success of the trauma scores in distinguishing patients with/without life threatening conditions. Logistic regression analysis was performed to measure the association between trauma scores and life threatening conditions. RESULTS: The relations between all scores and groups (with and without life threatening risk) were found statistically significant. ISS was the most successful method in distinguishing traumatised patients both in a life threatening or non life threatening condition. CONCLUSIONS: Trauma scores can be used for making more objective, standardised, and accurate judgement on whether the injury was a life threatening one or not. These advantages of using trauma scores in such situations will also be helpful for the conclusion of the lawsuits shortly, but further studies are needed to confirm these findings.

Long-term results of pediatric kidney transplantation at one center in Turkey.

Kidney transplantation is considered the treatment of choice for children with end-stage renal disease (ESRD). From November 1975 to June 2004, 80 of a total of 1477 kidney transplantations were performed in 78 pediatric patients. We retrospectively reviewed the records of 42 boys and 36 girls. Patient age ranged from 8 to 16 years (mean, 14.9 +/- 2.2). Sixty-three (78.7) grafts were from living donors and 17 (21.3%) from deceased donors. Two patients (2.6%) underwent preemptive transplantation, while 76 had preoperative renal replacement therapy with either hemodialysis in 62 (79.5%) or peritoneal dialysis in 14 (17.9%). Although the cause of ESRD could not be established in 30 cases, the other 48 showed the most common etiologies to be reflux nephropathy and glomerulonephritis. In conclusion, despite relatively poor socioeconomic conditions and health care problems in our country, the overall outcomes for pediatric patients at our transplantation center are good. We seek to perform more preemptive kidney transplantations in children with ESRD, and to increase our efforts to educate the Turkish public about organ transplantation and donation.

Switchability of neoral and equoral according to Food and Drug Administration rules and regulations.

According to the US Food and Drug Administration (FDA), if a drug product contains a drug substance that is chemically identical and is delivered to the site of action at the same rate and extent as another drug product, then it is equivalent and can be substituted (switchable) for that drug product. Methods used to define bioequivalence as stated by the FDA rules (FDA 21 CFR 320, 24) are (1) pharmacokinetic (PK) studies in healthy volunteers, (2) comparative clinical trials, and (3) pharmacodynamic (PD) studies (bioactivity). We evaluated the switchability of Equoral (IVAX-USA) with Neoral (Novartis Switzerland using all FDA rules. In a single oral dose, we undertook a comparative bioavailability study of Equoral (IVAX, USA) Neoral (Novartis, USA), and Neoral (Novartis UK). The pharmacokinetics of Equoral and Neoral were determined with blood levels at 0, 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 3.5, 4, 5, 6, 8, 10, 12, 16, 24, 30, 36, 42, and 48 hours. The area under curve (AUC), AUC extrapolated to infinity (AUC0-inf), rate of absorption (Tmax), extent of absorption (Cmax), half time (t1/2) of Equoral and Neoral were all within the 90% confidence interval of 80% to 125% boundaries. A comparative multinational multicenter clinical trial in stable renal transplant patients included 70 patients (22 women and 48 men) of mean age of 33 years (range, 26 to 43) was performed in Turkey, Lebanon, and Pakistan. In this study the ratios of LSM and the 90% confidence intervals for the Nontransformed/Parameters (AUC0-t, AUCinf, Tmax, and Cmax) of Equoral and Neoral SGC were 98% and 95%, respectively, which are within the 80% to 125% FDA acceptance range. For immunosuppressive drugs, the site of action is the lymphocyte and the measurable response is the decrease in lymphocyte count caused by the relative concentration of the drug in the lymphocyte. In a controlled switch, fixed-dose study, both Equoral and Neoral achieved the same concentration in the lymphocytes and caused the same degree of lymphocyte count reduction. The results of the testing (bioavailability-bioequivalence, clinical studies, and pharmacodynamic-bioactivity) required by FDA for interchangeability ("switchability") of immunosuppressive agents suggests that Neoral and Equoral are switchable.

Living-related liver transplantation in pediatric patients.

INTRODUCTION: Many developments in surgical technique, immunosuppression, and patient selection criteria have led to improved long-term patient and graft survival in pediatric patients receiving liver transplants. In this study, we examined the early results of 26 pediatric recipients who underwent 26 liver transplantations between January 2003 and December 2004 at our institution. MATERIALS AND METHODS: The most common indications for liver transplantation were cholestasis in 10 patients (38.5%) and Wilson's disease in 8 (30.8%). Other indications were fulminant hepatic failure (4 patients, 15.4%), tyrosinemia (2 patients, 7.7%), Caroli disease (1 patient, 3.8%), and cryptogenic cirrhosis (1 patient, 3.8%). One recipient with Byler disease and two with tyrosinemia also had incidental hepatocellular carcinoma. RESULTS: Of 26 patients, 24 (92.3%) underwent living-related liver transplantation and 2 (7.7%) underwent cadaveric transplantation. The medical records of all patients were retrospectively reviewed. Twenty-two of 26 survived with excellent graft function, showing 91.2%, 86.4%, and 81.6% at 3, 12, and 24 months graft and patient survival rates, respectively. Sixteen patients (61.5%) developed various morbidities with biliary and vascular complications being the most common. Four patients (15.3%) developed bile leaks. Four patients (15.3%) developed hepatic artery thromboses. Five patients (19.2%) developed life-threatening infections. Four patients (15.4%) died during the study period, three owing to infectious complications. The other patient died due to acute respiratory distress syndrome. CONCLUSION: Despite technical difficulties and a donor organ shortage, the results of liver transplantation in pediatric patients with end-stage liver disease have demonstrated promising results at our institution.

Duct-to-duct biliary anastomosis with a "corner-saving suture" technique in living-related liver transplantation.

OBJECTIVES: Biliary complications after living-related liver transplantation (LRLT) remain a major source of morbidity for recipients. We describe our technique and early results with 32 recipients who underwent LRLT with duct-to-duct anastomoses during the last 2 years. METHODS: Between January 2003 and December 2004, 50 patients underwent liver transplantation in our center with overall patient and graft survival rate of 86.4% and 86.4%. Of 50 patients, 41 (82.0%; 17 adult and 24 pediatric) underwent LRLT, 32 (78.0%) of whom had duct-to-duct biliary anastomoses with a "corner-saving suture" technique. RESULTS: Of 32 patients in whom duct-to-duct biliary anastomoses were performed, 4 (12.5%) had an anastomotic leak with 2 eventually developing bile duct strictures within 3 months. One patient required reoperation for a bile leak. All other anastomotic leaks and strictures were treated with percutaneous drainage and balloon dilatation with excellent outcomes. There was no long-term morbidity and no graft loss owing to biliary complications. Seven patients died during follow-up (0.5 to 25 months); 43 are doing well with optimal liver function in the early posttransplantation period. CONCLUSION: According to our early results, we recommend duct-to-duct anastomosis in LRLT when calibration of the ducts show suitable results and when there is no tension on the anastomosis site. Otherwise, Roux-en-Y hepaticojejunostomy should be performed to decrease risk of biliary complications.

Long-term results of pediatric renal transplantation at one center in Turkey.

Kidney transplantation is more frequently indicated in children than in adults because growth retardation is an additional problem associated with chronic kidney disease in the pediatric age group. This study retrospectively analyzed the data from 75 kidney transplantations performed on 73 children (38 male and 35 female) at a center in Turkey from late 1975 through 2003. The aim of the study was to investigate the case characteristics and the long-term outcomes in this patient group. Patient ages ranged from 8 to 16 years (mean, 14.9 +/- 2.2 years). Sixty (82.1%) children were on hemodialysis, and 12 (16.4%) on peritoneal dialysis prior to transplantation. Pre-emptive transplantation was performed for one (1.4%) patient. Fifty-nine transplantations used organs from live donors (78.7%) and 16 cadaver transplants (21.3%). The mean cold ischemia time for the cadaveric transplantations was 38.6 hours (range, 23-56 hours). All recipients were placed on a low-dose immunosuppressive regimen. One graft was lost due to hyperacute rejection. Twenty-one patients (28.8%) experienced a total of 24 acute rejection episodes. The follow-up period ranged from 1 to 190 months (mean, 44.1 +/- 31.8 months). Concerning postoperative complications, four patients (5.5%) developed a lymphocele; there were two cases each (2.7% each) of distal ureteral stricture, perirenal hematoma, or renovascular stenosis; and one patient (1.4%) developed a urine leakage. Two patients (2.7%) developed Kaposi's sarcoma at 17 and 3 months after transplantation. Six recipients died (mortality 8%), four of whom had a functioning graft. Two patients (2.7%) underwent retransplantation at 4 and 2 years after the initial operation. The 1-, 3-, and 5-year graft survival rates for living-related transplantations were 92%, 81%, and 70%, and the corresponding patient survival rates were 98%, 93%, and 92%, respectively. The 1-, 3-, and 5-year graft survival rates for cadaveric transplantations were 90%, 78%, and 68%, and patient survival rates 98%, 91%, and 90%, respectively. These results indicate that kidney transplantation is successful in pediatric end-stage renal disease patients particularly from living-related donors.

Prevalence of depression as measured by the CBDI in a predominantly adolescent school population in Turkey.

OBJECTIVES: This cross-sectional randomised study involving a predominantly adolescent school population (ranging from the 6th to the 11th grades) was conducted to determine the prevalence and clinical characteristics of depression in adolescents in the city of Mersin, Turkey. SUBJECTS AND METHODS: A stratified sample of 4256 students was selected as representative of the city's adolescent school population. The students were divided into two groups according to diagnosis (Group I: depressive adolescents; Group II: adolescents without depression). The age range varied between 10 and 20 years, with a mean of 14.53 years (S.D. = 1.89), i.e. a mean of 14.73 years (S.D. = 1.79) for Group I, and 15.5 years (S.D. = 1.9) for Group II. Data was obtained via two structured questionnaires designed to determine the presence and clinical characteristics of depression both in adolescents and in their parents. In addition, the Child Beck Depression Inventory (CBDI) was administered to all students participating in the study. After quality control of data, the study sample was reduced to 4143 adolescents. The mean age of the students was 11.23 +/- 6.44 years, and the ratio of boys/girls was 1.19:1. RESULTS: The prevalence of depression according to the CBDI (cut-off point: 19) was found to be 12.55% in this study group, with a significantly higher prevalence of depression in girls than in boys. Binary regression analysis demonstrated that the most important factors involved in the onset of depression in adolescents were having problems with parents, staying down a grade, and humiliation at school, and that the most common symptoms were feelings of worthlessness/guilt, sadness, emptiness, irritability and somatic disorders. CONCLUSION: This cross-sectional prospective randomised school-based study has examined sociodemographic and clinical characteristics of adolescents with depression in a student population. It was found that in this study group there was a relatively high level of depressive symptoms, with a clear predominance of females over males. Other clinical characteristics of adolescents with depression have been discussed in the context of previous investigations.

Health care professionals' knowledge of procedural issues in transplantation: the need for continuing education programs.

Organ transplantation is a multidisciplinary field that requires a good knowledge of the processes and excellent cooperation throughout the entire hospital. The aim of this study was to determine the level of knowledge of health care professionals (HCPs) at our transplantation center concerning general definitions and procedural issues related to transplantation. A questionnaire including nine items-five questions on general definitions and four on procedural issues-was distributed to 100 randomly selected HCPs. Four participants were excluded because they completed the questionnaire incorrectly; thus, there were 96 total respondents. The mean number (+/-SD) of correct answers overall was 5.78 +/- 1.36. Concerning general definitions, 11.5% of the respondents answered all of the questions correctly. However, the corresponding rate for the procedural questions was 3.1%. One percent of the respondents answered 1 or zero definition questions correctly, and 19.8% answered 1 or zero procedural questions correctly. The HCPs showed better knowledge of general issues related to transplantation than procedural issues. The results of this study suggest that the knowledge of HCPs in transplantation centers in Turkey is limited to the extent that their specialty is linked to transplantation. It is important that continuing medical education programs be instituted in organ procurement and transplantation centers in Turkey. These in-service training programs would enhance HCPs' understanding of and participation in procedures related to transplantation, and thus improve the total quality of the transplantation process.

The pharmacokinetics of equoral versus neoral in stable renal transplant patients: a multinational multicenter study.

We studied the pharmacokinetics (PKs) of the new generic cyclosporine formulation, Equoral capsules, after the switch from original formulation Neoral capsules in stable renal transplant patients. The study was carried out in accordance with the basic principles defined in the US 21 CFR Part 312.20 and the principles of the Declaration of Helsinki. The study included clinically stable first renal transplant patients maintained on cyclosporine with no rejection episode during the past 6 months. Hematology, biochemistry, and urine chemistry were determined on day 7, and day 21. The patients were all switched to Neoral (lot number 416MFD0601) on day 0 when the first sparse sampling PK was performed. On day 14 a 12-hour PK profile included predose, 30 minutes; 1 hour; 1 hour 30 minutes; 2 hours; 3 hours; 4 hours; 5 hours; 6 hours; 8 hours; 10-hours and 12-hour samples. Cyclosporine levels were determined using a CYA kit (Abbott TDx). On day 15 the patients were switched from Neoral capsules to Equoral capsules (lot 5T111014) at an equivalent dosage (mg/mg). The second sparse sampling PK was performed on day 21 and a 12-hour PK was performed on day 28. On the morning of day 29 patients were switched from Equoral capsules to Neoral capsules at an equivalent dosage (mg/mg). Additional concentrations were measured on days -7, 18, and 35. Safety parameters were monitored at each visit. The pharmacokinetics of both formulations were equivalent. The mean AUC for Neoral and Equoral was 2856 and 2892, respectively. The ratios of LSM and the 90% confidence intervals for the in-transformed parameters (AUC o-t, AUC inf, and Cmax) of Equoral and Neoral SGC were 98% and 95%, respectively, suggesting that Equoral and Neoral SGC are bioequivalent.

Tacrolimus conversion in kidney transplant recipients: analysis of 107 patients.

Early results of an alteration in immunosuppressive protocol of tacrolimus conversion at a mean follow-up of 16 (range 1 to 36) months are presented with a mean time after transplantation of 34 +/- 1.4 months (range 1 to 158 months). Chronic allograft nephropathy in 16 (17%) patients, nephrotoxicity related to cyclosporine in 27(23%) patients and steroids resistant acute rejection in 64 (58%) represented the indications for tacrolimus conversion. Before starting tacrolimus there were 1 acute rejection episode in 37 patients, 2 in 17 patients, and 3 in 10 patients. After the drug conversion, 1 acute rejection occurred in 18 and 2 acute rejection in 4 patients. Graft loss was seen in 16 (16%) patients after drug conversion. Tacrolimus was withdrawn due to diabetes mellitus (n = 9), epilepsy (n = 4), and severe Nocardia sepsis, lymphoma and Kaposi sarcoma (each in one patient). Decreases in serum creatinine and increases in blood glucose levels were significantly associated with the tacrolimus doses (P = 0.0004 and P = 0.0400, respectively). The increase in creatinine clearance values were closely related to higher tacrolimus levels. The target range with maximum efficacy and minimum toxicity seemed to be 10 to 15 ng/mL. Tacrolimus conversion can be successful in cases of rejection and nephrotoxicity, but dose-dependent blood glucose elevations require close observation in these patients.

Immunosuppressive therapy and Kaposi's sarcoma after kidney transplantation.

Immunosuppressive therapy for organ transplant recipients is complicated by high rates of malignant diseases, one of which is Kaposi's sarcoma (KS). Between November 1975 and March 2003, 1425 patients underwent renal transplantation at our center, including the 1095 most recent procedures. Fifty-two malignancies were observed in 50 patients (4.7%), including 16 cases of KS. The 16 recipients comprised 6 men and 10 women of mean age 39 +/- 9 years (range 10 to 62 years). At the time of KS diagnosis, 14 recipients were receiving cyclosporine, azathioprine, and prednisolone, and the other 2 azathioprine and prednisolone. The mean time from transplantation to diagnosis was 24 +/- 15.2 months (range 8 to 74 months). One recipient showed a lymphoma concomitant with KS. Seven patients had lesions limited to the skin, 5 had the skin and gastrointestinal tract disease, and 4 had disseminated disease. After KS was confirmed, the first-line treatment was cyclosporine and azathioprine withdrawal with tapering of prednisolone. The tumors were managed by appropriate surgical and/or medical therapy. At the time of this presentation, 9 individuals are alive, 4 with normal renal function. Five patients lost their grafts due to chronic rejection. We found that the combination of immunosuppressive drug withdrawal and chemotherapy is effective in patients with limited disease, but the results are poor in cases of generalized disease.

Problems in postoperative renal transplant recipients who present to the emergency unit: experience at one center.

When a renal recipient in Turkey develops a postoperative problem, consultation by the transplant team in the emergency unit is often the first step toward a solution. The main aim of this study was to identify the types of postoperative problems that cause renal transplantation patients to visit the emergency room. Gathering this information was believed to be an important step toward developing new management strategies for these problems, in line with the quality management systems used throughout our hospital network. We collated the physical signs in the 78 patients when they presented to the emergency room. The most common one was fever (26.9%) followed by nausea/vomiting, diarrhea, abdominal pain, dyspnea, skin lesions, headache, musculoskeletal trauma, hematuria/dysuria, epistaxis, psychological disorders, angina pectoris, hypertension, epilepsy, and rectal bleeding. Among the 78 patients, 45 (57.7%) were hospitalized and 33 (42.3%) were discharged with medical advice or drug treatment. Among the 45 hospitalized patients, 97.8% were initiated on medical treatment. Knowing the surgical and medical emergency issues prevalent in recipients enables the development of new procedures and algorithms, leading to more effective management and follow-up of renal transplant recipients.

The impact of cyclosporine on the development of immunosuppressive therapy.

The first immunosuppressive regimens based on glucocorticoids and azathioprine were introduced in the early 1960s. However, many patients developed acute rejection, which required treatment with high doses of prednisolone. Leading to a high mortality due to opportunistic infection. Prior to 1985, our center used a regimen of prednisolone and azathioprine for 352 renal transplantations with 1-year graft and patient survival rates of 63.9% and 82.4%, respectively. Cyclosporine was introduced into clinical practice in 1978, enabling more effective control of acute rejection. In 1985, our center adopted a protocol consisting of prednisolone, azathioprine, and cyclosporine producing significantly increased 1-, 3-, and 5-year patient and graft survival rates for living-related and cadaveric renal transplants. Newer drug combinations, which are less toxic and more potent than cyclosporine based protocols, have further decreased acute rejection rates from 60% to approximately 10%. Still, graft loss continues to be a problem. We believe that the most recent strategy of combining monoclonal antibodies with less toxic agents, such as sirolimus and mycophenolate mofetil, may eventually replace calcineurin inhibitors. Such protocols would eliminate the side effects of calcineurin inhibitors, and possibly permit steroid-free maintenance therapy. The immunosuppressive therapy that is currently available is not ideal; the ability to convert patients to a state of permanent immunologic tolerance would minimize the need for these drugs. The new generation of agents that includes FTY 20, anti-sense oligonucleotides, and agents capable of blocking the costimulatory pathway of allorecognition may improve host tolerance.