Basiliximab in association with tacrolimus and steroids in caucasian cadaveric renal transplanted patients: significant decrease in early acute rejection rate and hospitalization time

Comparison of tacrolimus with a cyclosporine microemulsion for immunosuppressive therapy in kidney transplantation

OBJECTIVE

To compare the efficacy and side effects of a cyclosporine microemulsion and tacrolimus in immunosuppressive therapy of renal transplantation.

MATERIAL AND METHODS

Between March 2003 and June 2005, the patients who had undergone kidney transplantation surgery and who were administered either basiliximab, a cyclosporine microemulsion, mycophenolate mofetil and prednisolone or basiliximab, tacrolimus, mycophenolate mofetil and prednisolone for baseline immunosuppressive therapy were recruited to our study. We evaluated the results of an 18-month follow-up period. The donors were called back weekly for a follow-up in the first month, fortnightly in the second month and then monthly for 18 months after discharge. A total of 41 patients were included in the study. The patients were evaluated as for demographic characteristics, acute rejection, cardiovascular and metabolic side effects, graft function, infections, hirsutism, gingival hyperplasia, cosmetic side effects, nephrotoxicity, drug changes and the survival rates.

RESULTS

There were no significant differences among the patients with regard to age, sex, donor type, dialysis periods, preoperative and postoperative systolic blood pressures, creatinine levels, hepatotoxicity, nephrotoxicity, occurrence of diabetes mellitus and the incidence of infection. The duration of hospitalization was prolonged in the cyclosporine A group. Acute rejection emerged in 5 patients (23.8%) in the tacrolimus group and in 4 patients (20%) in the cyclosporine A group. In the cyclosporin A group, the cholesterol and triglyceride levels were significantly higher than the tacrolimus group. The cosmetic side effects (gingival hyperplasia and hirsutism) as a reason for a change in medication were only observed in the cyclosporin A group, not in the tacrolimus group. A medication change was made in 8 patients in the cyclosporine A group and in 1 patient in the tacrolimus group. No death was observed in either group. Graft loss was observed in only 1 patient in the cyclosporine A group.

CONCLUSION

Regarding the cosmetic side effects and hyperlipidemia, tacrolimus was found to be superior to cyclosporine A. Where hyperlipidemia is considered to be a risk factor for cardiovascular disease, tacrolimus use should be considered as a more acceptable treatment modality. However, the immunosuppressive regimen should be evaluated individually.

The role of basiliximab in the evolving renal transplantation immunosuppression protocol

Basiliximab is a chimeric mouse-human monoclonal antibody directed against the alpha chain of the interleukin-2 (IL-2) receptor on activated T lymphocytes. It was shown in phase III trials to reduce the number and severity of acute rejection episodes in the first year following renal transplantation in adults and children, with a reasonable cost-benefit ratio. The drug does not increase the incidence of opportunistic infections or malignancies above baseline in patients treated with conventional calcineurin inhibitor-based immunosuppression. In the field of renal transplantation, basiliximab does not increase kidney or patient survival, despite the reduction in the number of rejection episodes. Basiliximab may reduce the incidence of delayed graft function. In comparison with lymphocyte-depleting antibodies basiliximab appears to have equal efficacy in standard immunological risk patients. Recently, IL-2 receptor monoclonal antibodies have been used with the objective of reducing or eliminating the more toxic elements of the standard immunosuppression protocol. Several trials have incorporated basiliximab in protocols designed to avoid or withdraw rapidly corticosteroids, as well as protocols which substitute target-of-rapamycin (TOR) inhibitors for calcineurin inhibitors.

Induction treatment with monoclonal antibodies for heart transplantation

Individualization of induction therapy for heart transplantation (HT) is needed, given that only patients at significant risk for fatal rejection seem to present a favorable risk-benefit ratio. The question whether monoclonal interleukin 2 antagonists or antilymphocyte antibodies should be recommended remains unanswered. As most studies suggest that they have similar efficacy in preventing acute rejection, other variables related to safety or management costs should be taken into account. The cytokine release syndrome, associated with the use of OKT3, complicates management of HT patient. The experience in our center with 2 consecutive cohorts, treated with basiliximab (BAS) and OKT3, respectively, suggests that the use of BAS is associated, in addition to similar immunosuppressive efficacy and better safety profile than OKT3, with simpler patient management during the initial hospital stay, which could be associated with a reduction in posttransplant costs. Because few centers continue to use OKT3 as induction therapy in HT, more studies comparing cost-effectiveness of BAS vs polyclonal antilymphocyte antibodies (ATG) are needed.

Hospitalization Databases: A Tool for Transplantation Monitoring

INTRODUCTION

We sought to account for changes in posttransplant hospitalization patterns in terms of the changes in demographic and transplantation-related variables.

METHODS AND MATERIALS

We retrospectively analyzed 1860 cases of kidney transplantation performed between 1992 and 2004 in terms of demographic and transplantation-related variables. Of the 1860 cases, rehospitalization records in the first year posttransplantation were available for 1152 cases, which were assessed for causes of admission, mortality, graft loss, length of stay, and hospital charges.

RESULTS

The pattern of rehospitalizations showed the following trends: (1) Increased rate of infection; (2) Decreased rate of graft rejection; and (3) Peak costs of rehospitalization between 1999 and 2000.

CONCLUSION

We believed that the increased infection rate and decreased rejection rate may have been related at least partly to the shift in the treatment protocol from azathioprine-based to mycophenolate mofetil regimens in 2000. Furthermore, the peak in the relative frequency of diabetes mellitus and hypertension as the etiology of end-stage renal disease among those having undergone transplantation between 1999 and 2000 may have been responsible for the peak in rehospitalization costs and length of hospital stay. We are strongly of the opinion that hospital statistics are a valuable tool for health care policymakers to monitor transplantation outcomes.

Use of IL-2 receptor antagonists to reduce delayed graft function following renal transplantation: a review

Delayed graft function (DGF) occurs in approximately 30% of renal transplant patients, and significantly increases risk of long-term graft loss. This article reviews the potential for use of interleukin-2 receptor (IL-2R) antagonists to reduce the burden of DGF. IL-2R antagonists decrease incidence of acute rejection without increasing risk of cytomegalovirus infection or malignancy, and show equivalent efficacy to lymphocyte-depleting antibody agents in standard risk patients with immediate graft function. The nephrotoxicity associated with calcineurin inhibitors (CNIs) has led to use of delayed or low-dose CNI regimens with induction therapy in patients with DGF. In this setting, use of an IL-2R antagonist with mycophenolate mofetil and steroids with delayed cyclosporine appears to be associated with a low incidence of biopsy-proven rejection and comparable renal function to patients with immediate function. Additionally, there is intriguing evidence to suggests that IL-2R antagonists may reduce risk of DGF occurring. A number of large-scale and smaller studies have reported a trend to reduced incidence of DGF or improved early renal function using IL-2R antagonists compared with placebo, although data are not entirely consistent. In conclusion, the ability of IL-2R antagonists to reduce acute rejection with no additional safety concerns makes them an attractive option for patients with DGF.

Efficacy and safety of basiliximab in kidney transplantation

The efficacy and safety of basiliximab, in combination with different maintenance regimens, are extensively addressed in the available literature. Basiliximab reduces the incidence of acute rejection, allows a safe reduction of steroid dosage, and is associated with economic savings, although there is substantially no proof that basiliximab prolongs either patient or graft survival. Initial basiliximab administration entails a low-risk and is associated with fewer adverse events than T cell depleting agents. However, life-threatening reactions were reported following re-exposure to basiliximab in recipients who lost graft function early after transplantation and, therefore, discontinued all immunosuppressive agents.