Immunosuppression Protocols for HLA Identical Renal Transplant Recipients E. Keitel, A.F. Santos, M.A. Alves, J.P. Neto, P.G. Schaefer, A.E. Bittar, J.C. Goldani, R. Pozza, R.M. Bruno, D. See, C.D. Garcia, and V.D. Garcia
I
MMUNOSUPPRESSIVE protocols for renal transplant recipients of HLA identical living related donors have been debated in the literature.1–3 We evaluated the results of two protocols for HLA identical renal transplant recipients with respect to the acute rejection episodes during the first posttransplantation year, to renal function and to incidence of graft survival.
METHODS A retrospective analysis of 67 renal transplants from HLA identical donor was performed, using case from January 1990 to May 2000 each of which had at least 6 months’ follow-up. Five were second and one was a third transplant; 41 (61.2%) were men. The mean age was 34.2 ⫾ 9.8 years. Up to April 1995, all primary HLA identical transplant recipients received azathioprine (Aza) ⫹ prednisone (Pred ⫽ 20 mg/kg; group I [GI] ⫽ 33 patients). From May 1995 to May 2000, they received triple therapy with Aza ⫹ Pred ⫹ microemulsion cyclosporine (group II [G2] ⫽ 34 patients). All recipients of second or third transplants received triple therapy. An intention-to-treat analysis used the Student t test to compare mean values and the Kaplan-Meier method for graft survival.
RESULTS
There was a significant difference in the incidence of acute rejection episodes between GI (n ⫽ 13; 39.4%) versus GII
(n ⫽ 5; 14.7%; P ⫽ .03). No difference was seen in the renal function as evaluated by estimated creatinine clearance in the two groups during the follow-up. At the 3rd year in GI it was 76.6 ⫾ 30.7 mL/min, and in GII, 71.6 ⫾ 19.0 mL/min (P ⫽ NS). Actuarial graft survivals are shown in Fig. 1. During the follow-up there were 8 graft losses in GI and 3 in GII. The causes of graft loss were acute rejection (GI:3 vs GII:1), chronic rejection (GI:2 vs GII:2), death with a functioning graft (GI:2), and recurrence of original disease (GI:1). DISCUSSION AND CONCLUSIONS
Regardless of the immunosuppressive protocol, HLA-identical sibling transplants provided excellent results, with 5-year graft survival rates of about 90%, and superior graft half-lives of up to 42 years in Caucasian recipients.4 Comparison of CyA protocols to those with Aza plus Pred shows our data to be different from those published by Moon et From the Renal Transplant Unit, Santa Casa Hospital, Porto Alegre, RS, Brazil. Address reprint requests to Dr Elizete Keitel, Fernandes Vieira 634/803, Porto Alegre, RS, Brazil, 90035-090. E-mail:
[email protected]
Fig. 1. Actuarial graft survival rates. 0041-1345/03/$–see front matter doi:10.1016/S0041-1345(03)00313-0
© 2003 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710
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al,1 who found a similar incidence of rejection episodes and of long-term patient and graft survivals among HLAidentical siblings regardless of taking Aza or CyA. Peddi et al3 observed acute rejection episodes only in patients who did not receive initial CyA or following CyA withdrawal. However, they found similar 10-year graft survivals among patients without versus with initial CyA immunosuppression (68.8% and 70%). Conversely, MacDonald et al2 reported 12-year posttransplant graft survivals of 84% in CyA-treated patients compared to 50% in Aza-treated patients. In conclusion, our data reveal an increased incidence of acute rejection episodes among the Aza-Pred therapy
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group. There was no difference in renal function between the two groups. Although the groups are small, there was a trend to better long-term actuarial graft survival in the triple-therapy group.
REFERENCES 1. Moon JI, et al: Surg Today 3:123, 2001 2. MacDonald AS, Belitsky P, Bitter-Suermann, et al: Transplant Proc 29:190, 1997 3. Peddi VR, Weiskittel P, Alexander JW, et al: Transplant Proc 33:3411, 2001 4. Cecka JM: Clinical Transplants 2000. p. 1
