Priority 4 from the Kidney Transplant PSP

UNCERTAINTY: Can we improve monitoring of the level of immunosuppression to achieve better balance between risk of rejection and side effects (e.g. T-cell or B-cell ELISPOT, point-of-care tacrolimus monitoring, MMF monitoring)
Overall ranking	Priority questions agreed on but not put in ranked order
JLA question ID	0037/4
Explanatory note	Not available for this PSP
Evidence	Existing Systematic Reviews - Wang, X, Qin, X, Wang, Y, Huang, Z, Li, X, Zeng, Q, Zeng, H, Lu, Y, Wang, L, Lin, T. Controlled-dose versus fixed-dose mycophenolate mofetil for kidney transplant recipients: a systematic review and meta-analysis of randomized controlled trials. Transplantation. 2013;96(4):361-7 ~ Knight, S. R., Morris, P. J. Does the evidence support the use of mycophenolate mofetil therapeutic drug monitoring in clinical practice? A systematic review. Transplantation. 2008;85(12):1675-85 ~ Knight SR, Morris PJ. The clinical benefits of cyclosporine C2-level monitoring: a systematic review. Transplantation. 2007 Jun 27;83(12):1525-35. Ongoing Randomised Controlled Trials: Individually Adapted Immunosuppression in de Novo Renal Transplantation Based on Immune Function Monitoring: a Prospective Randomised Study (CD4-01) - NCT00895206 ~ Sommerer, C., Schaier, M., Morath, C., Schwenger, V., Rauch, G., Giese, T., Zeier, M. The Calcineurin Inhibitor-Sparing (CIS) Trial - individualised calcineurin-inhibitor treatment by immunomonitoring in renal allograft recipients: protocol for a randomised controlled trial Trials. 2014;15:489
Health Research Classification System category	Renal and Urogenital

Extra information provided by this PSP
Original uncertainty examples	How can we monitor level of immunosuppression and immune activity ? Do markers of immune reactivity (e.g. T-cell or B-cell ELISPOT) help paitient management? Is it possible to do finger prick point of care tacrolimus monitoring? Should blood levels of mycophenolic acid be monitored? Is the failure of a transplanted kidney mostly due to control of medication.
Comparison	Diagnostics
Submitted by	Patient x 1 Clinicians x 4
Outcomes to be measured	Patient and graft survival, graft function, adverse events

PSP information
PSP unique ID	0037
PSP name	Kidney Transplant
Total number of uncertainties identified by this PSP.	90 (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop	3 February 2016