Transplant immunology
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Transplant immunology · Nov 2008
Randomized Controlled Trial Comparative StudyComparison of four different immunosuppression protocols without long-term steroid therapy in kidney recipients monitored by surveillance biopsy: five-year outcomes.
Induction and maintenance immunosuppression protocols with or without long-term steroid therapy in kidney transplant recipients are variable and are transplant center-specific. The aim of this prospective randomized pilot study was to compare 5-year outcomes in kidney recipients maintained on 4 different calcineurin inhibitor (CNI)-based immunosuppression protocols without long-term steroid therapy. Two hundred consenting patients who received kidney transplants between June 2000 and October 2004 were enrolled in 4 immunosuppression protocol groups, with 50 patients in each group: cyclosporine (CSA)/mycophenolate mofetil (MMF), CSA/sirolimus (SRL), tacrolimus (TAC)/MMF, and TAC/SRL. ⋯ Serum creatinine levels and creatinine clearances at 5 years were comparable among the groups. Our data show that the rates of CAR and SCAR in the first year post-transplant were significantly lower in the CSA/SRL and TAC/SRL groups and that cumulative CAI rates due to IF/TA and HTN at 5 years were significantly lower in the TAC/MMF, TAC/SRL, and CSA/SRL groups than in the CSA/MMF group. Despite significant differences in the incidences of CAR and SCAR and prevalence of different types of CAI at 5 years, renal function and patient and graft survival rates at 5 years were comparable among kidney recipients maintained on 4 different immunosuppression protocols without long-term steroid therapy.
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Induction of tolerance, which obviates the need for maintenance immunosuppression following organ transplantation remains elusive. In cardiac transplantation, ongoing immunosuppressive therapy is essential to ensure long-term graft survival. Although drug regimens have substantially improved in recent years, their adverse effects continue to cause significant morbidity and affect quality of life. ⋯ In addition to the conventional clinical parameters which include therapeutic drug monitoring, endomyocardial biopsy and echocardiography, newer techniques for monitoring hold future promise. These include detection of circulating alloantibodies and quantitative measurement of the net state of immunosuppression (Cylex). However, the efficacy of these modalities requires further investigation.