Skip to main content

Immunosuppression — Perioperative Management

Build a medication plan with the transplant, rheumatology or IBD team before elective reconstruction. Balance infection and healing risks against allograft rejection or disease flare. An allograft recipient and a patient having renal autotransplantation are different: autotransplantation alone does not create a requirement for anti-rejection medication.

Record the indication, last dose, dosing interval, graft function, recent rejection/infection, blood counts and relevant drug interactions. Document the route while NPO and who will decide when to restart any deliberately withheld medicine.

Solid Organ Transplant Recipients​

In a stable recipient, maintenance calcineurin inhibitors, antimetabolites and required corticosteroids generally continue through surgery. Avoid missed doses; arrange alternative administration with transplant pharmacy when oral absorption is unreliable. Monitor calcineurin-inhibitor troughs and renal function when indicated. For kidney recipients taking sirolimus or everolimus, the EAU 2026 guideline strongly recommends drug-level monitoring to guide dose adjustment.[7] Macrolides and azole antifungals can markedly change exposure.[1]

Do not independently stop mycophenolate, tacrolimus or another maintenance agent because a fistula or operation is present. Infection, leukopenia, renal deterioration and recent rejection require transplant-team decisions. Sirolimus-related healing concerns may justify a planned interruption or substitution before major surgery; they do not support stopping every mTOR inhibitor without an alternative regimen.[1]

In a single-center retrospective cohort of 300 deceased-donor kidney recipients, rejection occurred in 7/20 (35%) whose immunosuppression was reduced for infection 2–6 months after transplantation, compared with 9/68 (13.2%) who had infection without a reduction.[2]

For adrenal-risk assessment and stress coverage, see Steroids. Required transplant treatment and adrenal replacement should be accounted for together without duplicate dosing.

Biologics: Use the Disease and Operation Context​

Biologic hold decisions depend on the disease, agent and operation.

ContextRelevant guidance and limit
Crohn's disease undergoing abdominal surgeryECCO 2024 recommends against stopping anti-TNF therapy or vedolizumab (EL3) or ustekinumab (EL4) before abdominal Crohn surgery.[3]
Ulcerative colitis undergoing surgeryECCO 2026 suggests biologics probably need not be stopped, considering the dosing interval and procedure. Evidence is limited, especially for pouch construction and small molecules; ECCO's accompanying text advises withholding tofacitinib and upadacitinib for 3 days before UC surgery; other small molecules need agent-specific planning.[4]
Inflammatory arthritis undergoing elective hip/knee arthroplastyACR/AAHKS 2022 conditionally recommends holding biologics and scheduling surgery after the next dose would be due. If withheld, restart after satisfactory healing and no infection, typically around 14 days. These recommendations concern arthroplasty; transfer to GU reconstruction requires specialist judgment.[5]
Same ACR/AAHKS 2022 guideline: non-biologic agentsFor patients with RA, AS, PsA, JIA or SLE undergoing elective hip or knee arthroplasty, ACR/AAHKS conditionally recommends continuing methotrexate, leflunomide, hydroxychloroquine and sulfasalazine through surgery. For RA, AS, PsA or JIA undergoing elective hip or knee arthroplasty, ACR/AAHKS conditionally recommends withholding tofacitinib, baricitinib and upadacitinib for at least 3 days before surgery based on infection risk (low-quality evidence).[5] For patients taking glucocorticoids for RA, AS, PsA or SLE during elective hip or knee arthroplasty, continue the current daily dose rather than adding supraphysiologic dosing on the day of surgery (conditional, low-quality evidence; excludes primary adrenal insufficiency and primary hypothalamic disease).[5]

These distinctions prevent applying an orthopedic biologic schedule automatically to Crohn-related bowel and urinary reconstruction. For Crohn-related abdominal surgery, ECCO 2024 recommends tapering systemic corticosteroids when feasible to reduce complications (EL2); coordinate this with disease control and the Steroids plan.[3] Optimize nutrition, inflammation and infection control without provoking an avoidable flare. For elective hip or knee arthroplasty, ACR/AAHKS conditionally recommends withholding mycophenolate, azathioprine, cyclosporine and tacrolimus for one week in nonsevere SLE, but continuing them in severe SLE; these schedules require a disease-specific plan before GU reconstruction and do not override transplant maintenance.[5] In the same arthroplasty population, the guideline conditionally recommends withholding belimumab and rituximab in nonsevere SLE; in severe SLE, it recommends continuing belimumab and planning surgery in the last month of the rituximab dosing cycle.[5] Individual small-molecule therapies also need specialist plans.[5][3][4][5]

For Crohn-related fistulas, first define the anatomy and drain sepsis. ECCO's recommendation for preliminary seton drainage concerns complex perianal fistulas; it is not an instruction to pass a seton through an enterovesical or other urinary tract fistula. Coordinate bowel, urinary and pelvic drainage or diversion as appropriate.[3]

Infection, Drainage and Reconstruction​

Treat symptomatic infection, drain infected collections and establish reliable urinary drainage. Defer elective definitive repair or prosthetic implantation during uncontrolled infection; urgent source-control procedures should not wait for elective optimization. See Transplant urinary leak for anatomy-specific management.

For kidney transplant recipients more than 1 month after transplantation, IDSA recommends against screening for or treating asymptomatic bacteriuria ; it makes no recommendation for or against either approach during the first month because evidence is insufficient.[6] Colonization alone is not an indication for prolonged antibiotics. IDSA recommends screening for and treating asymptomatic bacteriuria before endoscopic urologic procedures that traumatize mucosa . It suggests culture-directed therapy as a short course of 1 or 2 doses started 30 to 60 minutes beforehand . Its suggestion for AUS or penile-prosthesis implantation differs: no ASB screening or treatment (weak, very low-quality evidence), while standard perioperative prophylaxis remains necessary. Active infection and operations entering an infected urinary tract require their own treatment plan.[6]

Choose healthy tissue, drainage and any interposition flap according to the defect, perfusion, radiation, contamination and prior repairs. Coordinate medication changes, nutritional and glucose optimization and postoperative surveillance with the treating team.

References​

1. Mukadam M, Irshad Z. Transplant immunosuppression in the perioperative period. Royal College of Surgeons of Edinburgh, 2022. Professional guidance.

2. Yang B, Ye Q, Huang C, Ding X. Impact of infection-related immunosuppressant reduction on kidney transplant outcomes: a retrospective study considering the temporal dynamics of immunosuppressive requirements. Transpl Int. 2023;36:11802. doi:10.3389/ti.2023.11802

3. Adamina M, Minozzi S, Warusavitarne J, et al. ECCO guidelines on therapeutics in Crohn's disease: surgical treatment. J Crohns Colitis. 2024;18:1556–1582. doi:10.1093/ecco-jcc/jjae089

4. Adamina M, Kienle P, Chaparro M, et al. ECCO guidelines on therapeutics in ulcerative colitis: surgical treatment. J Crohns Colitis. 2026;20:jjag072. doi:10.1093/ecco-jcc/jjag072

5. Goodman SM, Springer BD, Chen AF, et al. 2022 ACR/AAHKS guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Care Res. 2022;74:1399–1408. doi:10.1002/acr.24893

6. Nicolle LE, Gupta K, Bradley SF, et al. IDSA 2019 clinical practice guideline for the management of asymptomatic bacteriuria. Clin Infect Dis. 2019;68:e83–e110. doi:10.1093/cid/ciy1121

7. European Association of Urology. EAU Guidelines on Renal Transplantation. Limited update, March 2026. Guideline.