IMMUNOMODULATING AGENTS Brief History. A.S. is a 47-year-old concert musician who experienced a progressive decline in renal function that ultimately led to renal failure. Kidney function was maintained artifi cially through renal dialysis until a suitable kidney transplant became available from a donor who died in an automobile accident. The kidney was transplanted successfully, and A.S. was placed on a prophylactic regimen of three different immunosuppressive drugs to prevent the rejection of the transplanted kidney. At the time of the transplant, cyclosporine was initiated at a dosage of 10 mg/kg of body weight each day. After 15 days, the dosage was decreased to 8 mg/kg per day and was progressively decreased over the next 2 months until a maintenance dosage of 4 mg/kg per day was achieved. On the day of surgery, he also received an intravenous dose of 0.5 g of methylprednisolone. Oral doses of methylprednisolone were then administered in dosages of 16 mg/d for the fi rst 3 months, 12 mg/d for the next 3 months, and 8 mg/d thereafter. A loading dose of 6 mg of sirolimus (Rapamune) was administered orally after the transplant, and sirolimus was then maintained at a dosage of 2 mg per day throughout the posttransplant period. Physical therapy was initiated in the intensive care unit (ICU) 1 day after the transplant to increase strength and to facilitate recovery from the surgery.

Problem/Infl uence of Medication. The therapist noted that several drugs were being used to prevent rejection, including rather high doses of methylprednisolone, a glucocorticoid agent. Glucocorticoids are notorious for their catabolic effects, and the therapist was concerned that muscle wasting and bone demineralization could impair this patient’s recovery from the transplant.

1. What interventions can the therapist administer to help offset the catabolic effects of the glucocorticoids?

2. How can the initial rehabilitation sessions transition to a long-term exercise program for this patient?