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Zheng X, Zhang W, Zhou H, Cao R, Shou Z, Zhang S, Cheng Y, Chen X, Ding C, Tang Z, Li N, Shi S, Zhou Q, Chen Q, Chen G, Chen Z, Zhou P, Hu X, Zhang X, Na N, Wang W. A randomized controlled trial to evaluate efficacy and safety of early conversion to a low-dose calcineurin inhibitor combined with sirolimus in renal transplant patients. Chin Med J (Engl) 2022; 135:00029330-990000000-00070. [PMID: 35861301 PMCID: PMC9532037 DOI: 10.1097/cm9.0000000000001866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The calcineurin inhibitor (CNI)-based immune maintenance regimen that is commonly used after renal transplantation has greatly improved early graft survival after transplantation; however, the long-term prognosis of grafts has not been significantly improved. The nephrotoxicity of CNI drugs is one of the main risk factors for the poor long-term prognosis of grafts. Sirolimus (SRL) has been employed as an immunosuppressant in clinical practice for over 20 years and has been found to have no nephrotoxic effects on grafts. Presently, the regimen and timing of SRL application after renal transplantation vary, and clinical data are scarce. Multicenter prospective randomized controlled studies are particularly rare. This study aims to investigate the effects of early conversion to a low-dose CNI combined with SRL on the long-term prognosis of renal transplantation. METHODS Patients who receive four weeks of a standard regimen with CNI + mycophenolic acid (MPA) + glucocorticoid after renal transplantation in multiple transplant centers across China will be included in this study. At week 5, after the operation, patients in the experimental group will receive an additional administration of SRL, a reduction in the CNI drug doses, withdrawal of MPA medication, and maintenance of glucocorticoids. In addition, patients in the control group will receive the maintained standard of care. The patients' vital signs, routine blood tests, routine urine tests, blood biochemistry, serum creatinine, BK virus (BKV)/ cytomegalovirus (CMV), and trough concentrations of CNI drugs and SRL at the baseline and weeks 12, 24, 36, 48, 72, and 104 after conversion will be recorded. Patient survival, graft survival, and estimated glomerular filtration rate will be calculated, and concomitant medications and adverse events will also be recorded. CONCLUSION The study data will be utilized to evaluate the efficacy and safety of early conversion to low-dose CNIs combined with SRL in renal transplant patients. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR1800017277.
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Affiliation(s)
- Xiang Zheng
- Department of Urology, Capital Medical University Beijing Chaoyang Hospital, Beijing 100020, China
| | - Weijie Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430032, China
| | - Hua Zhou
- Kidney Transplantation Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi 030012, China
| | - Ronghua Cao
- Department of Organ Transplantation, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Zhangfei Shou
- Department of Nephrology, Shulan (Hangzhou) Hospital, Hangzhou, Zhejiang 310000, China
| | - Shuwei Zhang
- Department of Urology, Ningbo Yinzhou Number. 2 Hospital, Ningbo, Zhejiang 315000, China
| | - Ying Cheng
- Department of Organ Transplantation, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, China
| | - Xuchun Chen
- Department of Organ Transplantation, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, China
| | - Chenguang Ding
- Institute of Kidney Transplantation, The First Affiliated Hospital, Medical College of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China
| | - Zuofu Tang
- Department of Kidney, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, China
| | - Ning Li
- Kidney Transplantation Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi 030012, China
| | - Shaohua Shi
- Kidney Transplantation Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi 030012, China
| | - Qiang Zhou
- Department of Kidney, Southwest Hospital, The First Hospital Affiliated to The Third Military Medical University (Army Medical University), Chongqing 400000, China
| | - Qiuyuan Chen
- Department of Organ Transplantation, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430032, China
| | - Zheng Chen
- Organ Transplant Center, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510260, China
| | - Peijun Zhou
- Kidney Transplantation Center, Department of Urology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200000, China
| | - Xiaopeng Hu
- Department of Urology, Capital Medical University Beijing Chaoyang Hospital, Beijing 100020, China
| | - Xiaodong Zhang
- Department of Urology, Capital Medical University Beijing Chaoyang Hospital, Beijing 100020, China
| | - Ning Na
- Department of Kidney, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, China
| | - Wei Wang
- Department of Urology, Capital Medical University Beijing Chaoyang Hospital, Beijing 100020, China
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Liwski R, Stepkowski S. The prospect for the diagnostic management team to streamline virtual and physical crossmatching. Transpl Immunol 2022; 73:101628. [DOI: 10.1016/j.trim.2022.101628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
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Bekbolsynov D, Mierzejewska B, Khuder S, Ekwenna O, Rees M, Green RC, Stepkowski SM. Improving Access to HLA-Matched Kidney Transplants for African American Patients. Front Immunol 2022; 13:832488. [PMID: 35401566 PMCID: PMC8989073 DOI: 10.3389/fimmu.2022.832488] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/02/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Kidney transplants fail more often in Black than in non-Black (White, non-Black Hispanic, and Asian) recipients. We used the estimated physicochemical immunogenicity for polymorphic amino acids of donor/recipient HLAs to select weakly immunogenic kidney transplants for Black vs. White or non-Black patients. Methods OPTN data for 65,040 donor/recipient pairs over a 20-year period were used to calculate the individual physicochemical immunogenicity by hydrophobic, electrostatic and amino acid mismatch scores (HMS, EMS, AMS) and graft-survival outcomes for Black vs. White or vs. non-Black recipients, using Kaplan-Meier survival and Cox regression analyses. Simulations for re-matching recipients with donors were based on race-adjusted HMS thresholds with clinically achievable allocations. Results The retrospective median kidney graft survival was 12.0 years in Black vs. 18.6 years in White (6.6-year difference; p>0.001) and 18.4 years in non-Black (6.4-year difference; p>0.01) recipients. Only 0.7% of Blacks received transplants matched at HLA-A/B/DR/DQ (HMS=0) vs. 8.1% in Whites (p<0.001). Among fully matched Blacks (HMS=0), graft survival was 16.1-years and in well-matched Blacks (HMS ≤ 3.0) it was 14.0-years. Whites had 21.6-years survival at HMS ≤ 3.0 and 18.7-years at HMS ≤ 7.0 whereas non-Blacks had 22.0-year at HMS ≤ 3.0 and 18.7-year at HMS ≤ 7.0, confirming that higher HMS thresholds produced excellent survival. Simulation of ABO-compatible donor-recipient pairs using race-adjusted HMS thresholds identified weakly immunogenic matches at HMS=0 for 6.1% Blacks and 18.0% at HMS ≤ 3.0. Despite prioritizing Black patients, non-Black patients could be matched at the same level as in current allocation (47.0% vs 56.5%, at HMS ≤ 7.0). Conclusions Race-adjusted HMS (EMS, AMS)-based allocation increased the number of weakly immunogenic donors for Black patients, while still providing excellent options for non-Black recipients.
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Affiliation(s)
- Dulat Bekbolsynov
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | - Beata Mierzejewska
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | - Sadik Khuder
- Department of Medicine and Public Health, University of Toledo, Toledo, OH, United States
| | - Obinna Ekwenna
- Department of Urology, College of Medicine, University of Toledo, Toledo, OH, United States
| | - Michael Rees
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
- Department of Urology, College of Medicine, University of Toledo, Toledo, OH, United States
- The of Alliance for Paired Donation, Maumee, OH, United States
| | - Robert C. Green
- Department of Computer Science, Bowling Green State University, Bowling Green, OH, United States
- *Correspondence: Stanislaw M. Stepkowski, ; Robert C. Green II,
| | - Stanislaw M. Stepkowski
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
- *Correspondence: Stanislaw M. Stepkowski, ; Robert C. Green II,
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El Hennawy HM, Faifi ASA, El Nazer W, Mahedy A, Kamal A, Al Faifi IS, Abdulmalik H, Safar O, Zaitoun MF, Fahmy AE. Calcineurin Inhibitors Nephrotoxicity Prevention Strategies With Stress on Belatacept-Based Rescue Immunotherapy: A Review of the Current Evidence. Transplant Proc 2021; 53:1532-1540. [PMID: 34020797 DOI: 10.1016/j.transproceed.2021.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/10/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND A traditional narrative review was performed to evaluate clinical studies that have examined the clinical implications, risk factors, and prevention of calcineurin inhibitors (CNIs) nephrotoxicity with stress on a belatacept-based rescue regimen. METHODS The Cochrane Library, PubMed/MEDLINE, EBSCO (Academic Search Ultimate), ProQuest (Central), and Excerpta Medical databases and Google scholar were searched using the keywords (CNI AND Nephrotoxicity prevention) OR ("Calcineurin inhibitor" AND Nephrotoxicity) OR (Tacrolimus AND Nephrotoxicity) OR (Ciclosporin AND Nephrotoxicity) OR (cyclosporine AND Nephrotoxicity) OR (Belatacept) OR (CNI Conversion) for the period from 1990 to 2020. Fifty-five related articles and reviews were found. CONCLUSION A better understanding of the mechanisms underlying calcineurin inhibitor nephrotoxicity could help in the individualization of therapy for and prevention of CNI nephrotoxicity. Identification of high-risk patients for CNI nephrotoxicity before renal transplantation enables better use and selection of immunosuppression with reduced adverse effects and, eventually, successful treatment of the kidney recipients. Belatacept conversion is a good and safe option in patients with deteriorating renal function attributed to CNI nephrotoxicity.
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Affiliation(s)
- Hany M El Hennawy
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia.
| | - Abdullah S Al Faifi
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Weam El Nazer
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed Mahedy
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed Kamal
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ibrahim S Al Faifi
- Department of Family Medicine, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Hana Abdulmalik
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Omar Safar
- Department of Urology, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Mohammad F Zaitoun
- Department of Pharmacy, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed E Fahmy
- Department of Surgery, Division of Transplantation, North Shore University Hospital, Northwell Health, Manhasset, New York
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Gilad O, Rabinowich L, Levy S, Gotlieb N, Lubezky N, Goykhman Y, Nachmany I, Katz P, Shibolet O, Katchman H. Metabolic and Renal Effects of Mammalian Target of Rapamycin Inhibitors Treatment After Liver Transplantation: Real-Life Single-Center Experience. Transplant Proc 2020; 53:221-227. [PMID: 32650991 DOI: 10.1016/j.transproceed.2020.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mammalian target of rapamycin (mTOR) inhibitors following liver transplantation (LT) are used to minimize calcineurin inhibitor (CNI)-related nephrotoxicity. Data about metabolic effects of mTOR inhibitors are still limited. AIM This study aims to determine the renal and metabolic effects of different mTOR inhibitor-based protocols in real-life LT patients. METHODS This is a retrospective cohort study of patients treated with mTOR inhibitors after LT. Demographics, treatment protocols, glomerular filtration rate (GFR), and metabolic parameters were collected over a period of 4 years. Initiation of blood pressure (BP), diabetes mellitus, and lipid medications was also noted. RESULTS Fifty-two LT recipients received mTOR inhibitors. GFR improved significantly (by 1.96 mL/min/year), with greater improvement in patients with baseline renal dysfunction (+13.3 mL/min vs +4.5 mL/min at 3 years). Conversion to an mTOR inhibitor during the first post-transplant year resulted in a more durable improvement in GFR (for 4 years vs only 1 year for later conversion).No significant weight gain or new-onset diabetes mellitus was observed. However, there was some increase in total cholesterol (+7 mg/dL) and blood pressure (+2 mm Hg during the third year and +8 mm Hg in the fourth years), followed by initiation of lipid-lowering and BP medications in 25% and 13% of patients, respectively. CONCLUSIONS Treatment with an mTOR inhibitor following LT resulted in improved kidney functions without significant negative metabolic effects such as weight gain or new-onset diabetes mellitus. This makes mTOR inhibitors a valuable immunosuppressive option in the face of the growing incidence of nonalcoholic steatohepatitis as a leading cause for LT.
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Affiliation(s)
- O Gilad
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - L Rabinowich
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Levy
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Gotlieb
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Lubezky
- Devision of Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Goykhman
- Devision of Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Nachmany
- Devision of Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - P Katz
- Devision of Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Shibolet
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Katchman
- Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Wilkins LJ, Nyame YA, Gan V, Lin S, Greene DJ, Flechner SM, Modlin CS. A Contemporary Analysis of Outcomes and Modifiable Risk Factors of Ethnic Disparities in Kidney Transplantation. J Natl Med Assoc 2018; 111:202-209. [PMID: 30409716 DOI: 10.1016/j.jnma.2018.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/29/2018] [Accepted: 10/05/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to provide a contemporary analysis of longitudinal kidney transplant outcomes and to evaluate potential causes of ethnic disparities among African American (AA) and Caucasian American (CA) patients undergoing kidney transplantation at our institution. PATIENTS AND METHODS 1400 patients were identified who underwent kidney transplantation from 2003 to 2013 from a large, academic institution in Cleveland, OH. Relevant recipient and donor demographic and clinical covariates were obtained from an institutional transplant database. Simple descriptive statistics and comparative survival analyses were performed to assess overall survival and graft survival. RESULTS The final cohort was comprised of 341 AA and 1059 CA patients. AAs were less likely to receive a living donor transplant (27.6% vs. 57.2%, p < 0.001) compared to CAs. Overall patient survival did not significantly differ between the two groups even when stratified by ethnicity. However, AAs had a significantly lower rate of graft survival (p < 0.001). On stratified analysis, there was no difference in the rate of graft survival among AAs and CAs who received living donor grafts. On univariate analysis, AAs demonstrated higher rates of immunosuppression non-compliance and chronic rejection (both p < 0.05). On multivariate analysis, AA recipient ethnicity (HR 1.56, p = 0.047), recipient history of diabetes (HR 1.67, p < 0.001), and AA donor ethnicity (HR 1.56, p = 0.047) were significantly associated with graft failure. CONCLUSION AAs undergoing deceased donor renal transplantation demonstrated lower graft survival compared to CAs. Conversely, this disparity did not exist among AAs undergoing living donor transplantation. AAs had higher rates of deceased donor transplantation, immunosuppression non-compliance, chronic rejection, and diabetes. Opportunities exist to use patient education, alternative immunosuppression regimens, and living transplantation to close the ethnic disparity in renal allograft survival.
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Affiliation(s)
- Lamont J Wilkins
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Lerner College of Medicine, Cleveland Clinic, Cleveland OH, USA
| | - Yaw A Nyame
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Valerie Gan
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Songhua Lin
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel J Greene
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stuart M Flechner
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles S Modlin
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
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Bohelay G, Arzouk N, Lévy P, Rabaté C, Le Cleach L, Barete S, Barrou B, Matignon MB, Euvrard S, Lebbé C, Francès C. Outcome of second kidney transplantation in patients with previous post-transplantation Kaposi's sarcoma: A French retrospective study. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Gérôme Bohelay
- Department of Dermatology and Allergology; University Paris VI; Hôpital Tenon; Paris France
| | - Nadia Arzouk
- Department of Urology; University Paris VI; Hôpital Pitié Salpêtrière; Paris France
| | - Pierre Lévy
- Department of Public Health; Hôpital Tenon; APHP; University Paris VI; and Institut National de la Santé et de la Recherche Médicale; UMR-S 1136; Paris France
| | - Clémentine Rabaté
- Department of Nephrology; University Paris V; Hôpital Necker; Paris France
| | - Laurence Le Cleach
- Department of Dermatology; AP-HP; Hôpitaux Universitaires Henri Mondor; Créteil France
- EA EpiDermE; INSERM Créteil; Créteil France
| | - Stéphane Barete
- Department of Dermatology and Allergology; University Paris VI; Hôpital Tenon; Paris France
| | - Benoît Barrou
- Department of Urology; University Paris VI; Hôpital Pitié Salpêtrière; Paris France
| | - Marie-Benedicte Matignon
- Department of Nephrology and Transplantation; Assistance Publique-Hôpitaux de Paris; Groupe Henri Mondor-Albert Chenevier; Centre d'Investigation Clinique-BioThérapies 504; Institut National de la Santé et de la Recherche Médicale U955; Paris XII University; Créteil France
| | - Sylvie Euvrard
- Department of Dermatology; Hôpital Edouard Herriot; Hospices Civils de Lyon; Lyon France
| | - Céleste Lebbé
- Department of Dermatology; APHP, University Paris VII; Hôpital Saint-Louis; Paris France
| | - Camille Francès
- Department of Dermatology and Allergology; University Paris VI; Hôpital Tenon; Paris France
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Karpe KM, Talaulikar GS, Walters GD. Calcineurin inhibitor withdrawal or tapering for kidney transplant recipients. Cochrane Database Syst Rev 2017; 7:CD006750. [PMID: 28730648 PMCID: PMC6483545 DOI: 10.1002/14651858.cd006750.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Calcineurin inhibitors (CNI) can reduce acute transplant rejection and immediate graft loss but are associated with significant adverse effects such as hypertension and nephrotoxicity which may contribute to chronic rejection. CNI toxicity has led to numerous studies investigating CNI withdrawal and tapering strategies. Despite this, uncertainty remains about minimisation or withdrawal of CNI. OBJECTIVES This review aimed to look at the benefits and harms of CNI tapering or withdrawal in terms of graft function and loss, incidence of acute rejection episodes, treatment-related side effects (hypertension, hyperlipidaemia) and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 11 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) where drug regimens containing CNI were compared to alternative drug regimens (CNI withdrawal, tapering or low dose) in the post-transplant period were included, without age or dosage restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 83 studies that involved 16,156 participants. Most were open-label studies; less than 30% of studies reported randomisation method and allocation concealment. Studies were analysed as intent-to-treat in 60% and all pre-specified outcomes were reported in 54 studies. The attrition and reporting bias were unclear in the remainder of the studies as factors used to judge bias were reported inconsistently. We also noted that 50% (47 studies) of studies were funded by the pharmaceutical industry.We classified studies into four groups: CNI withdrawal or avoidance with or without substitution with mammalian target of rapamycin inhibitors (mTOR-I); and low dose CNI with or without mTOR-I. The withdrawal groups were further stratified as avoidance and withdrawal subgroups for major outcomes.CNI withdrawal may lead to rejection (RR 2.54, 95% CI 1.56 to 4.12; moderate certainty evidence), may make little or no difference to death (RR 1.09, 95% CI 0.96 to 1.24; moderate certainty), and probably slightly reduces graft loss (RR 0.85, 95% CI 0.74 to 0.98; low quality evidence). Hypertension was probably reduced in the CNI withdrawal group (RR 0.82, 95% CI 0.71 to 0.95; low certainty), while CNI withdrawal may make little or no difference to malignancy (RR 1.10, 95% CI 0.93 to 1.30; low certainty), and probably makes little or no difference to cytomegalovirus (CMV) (RR 0.87, 95% CI 0.52 to 1.45; low certainty)CNI avoidance may result in increased acute rejection (RR 2.16, 95% CI 0.85 to 5.49; low certainty) but little or no difference in graft loss (RR 0.96, 95% CI 0.79 to 1.16; low certainty). Late CNI withdrawal increased acute rejection (RR 3.21, 95% CI 1.59 to 6.48; moderate certainty) but probably reduced graft loss (RR 0.84, 95% CI 0.72 to 0.97, low certainty).Results were similar when CNI avoidance or withdrawal was combined with the introduction of mTOR-I; acute rejection was probably increased (RR 1.43; 95% CI 1.15 to 1.78; moderate certainty) and there was probably little or no difference in death (RR 0.96; 95% CI 0.69 to 1.36, moderate certainty). mTOR-I substitution may make little or no difference to graft loss (RR 0.94, 95% CI 0.75 to 1.19; low certainty), probably makes little of no difference to hypertension (RR 0.86, 95% CI 0.64 to 1.15; moderate), and probably reduced the risk of cytomegalovirus (CMV) (RR 0.60, 95% CI 0.44 to 0.82; moderate certainty) and malignancy (RR 0.69, 95% CI 0.47 to 1.00; low certainty). Lymphoceles were increased with mTOR-I substitution (RR 1.45, 95% CI 0.95 to 2.21; low certainty).Low dose CNI combined with mTOR-I probably increased glomerular filtration rate (GFR) (MD 6.24 mL/min, 95% CI 3.28 to 9.119; moderate certainty), reduced graft loss (RR 0.75, 95% CI 0.55 to 1.02; moderate certainty), and made little or no difference to acute rejection (RR 1.13 ; 95% CI 0.91 to 1.40; moderate certainty). Hypertension was decreased (RR 0.98, 95% CI 0.80 to 1.20; low certainty) as was CMV (RR 0.41, 95% CI 0.16 to 1.06; low certainty). Low dose CNI plus mTOR-I makes probably makes little of no difference to malignancy (RR 1.22, 95% CI 0.42 to 3.53; low certainty) and may make little of no difference to death (RR 1.16, 95% CI 0.71 to 1.90; moderate certainty). AUTHORS' CONCLUSIONS CNI avoidance increased acute rejection and CNI withdrawal increases acute rejection but reduced graft loss at least over the short-term. Low dose CNI with induction regimens reduced acute rejection and graft loss with no major adverse events, also in the short-term. The use of mTOR-I reduced CMV infections but increased the risk of acute rejection. These conclusions must be tempered by the lack of long-term data in most of the studies, particularly with regards to chronic antibody-mediated rejection, and the suboptimal methodological quality of the included studies.
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Affiliation(s)
- Krishna M Karpe
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Girish S Talaulikar
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Giles D Walters
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
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