The long-term survival of simultaneous pancreas and kidney transplant with basiliximab induction therapy

Outcomes of Primary Simultaneous Pancreas-kidney Transplants by Induction Agent in the United States

Long-term outcome data by induction type in simultaneous pancreas-kidney (SPK) is limited.

METHODS

Utilizing the Scientific Registry of Transplant Recipients, we examined all primary SPK transplants between 2000 and 2020, excluding crossmatch-positive recipients. We grouped recipients according to induction regimen into 3 groups: rabbit anti-thymocyte globulin (r-ATG) (n = 5678), alemtuzumab (n = 1199), and interleukin-2 receptor antagonist (IL-2RA; n = 1593). We analyzed the 10-y recipient and composite (kidney and pancreas) graft survival using the Kaplan-Meier survival function. Cox-proportion hazard models were generated to examine the association between induction type, the 10-y recipient, and graft survival. Models were adjusted for recipient age, sex, ethnicity, HLA-mismatch, diabetes type, dialysis dependency, cold-ischemia time, local versus imported organs, panel reactive antibody, steroid maintenance, and Pancreas Donor Risk Index.

RESULTS

r-ATG was associated with the lowest 1-y kidney and pancreas rejection rates compared with other agents (P < 0.001). In the univariable analysis, induction type was not associated with recipient (log-rank P = 0.11) or graft survival (log-rank P = 0.36). In the multivariable model for the composite graft survival, alemtuzumab use was associated with 22% increased kidney or pancreas graft loss compared with r-ATG (adjusted hazard ratio, 1.22; 95% confidence interval, 1.05-1.42), whereas IL-2RA use was not a predictor of graft survival. Induction type did not influence recipient survival in the adjusted model.

CONCLUSIONS

r-ATG use was associated with the lowest SPK rejection rates. Compared with r-ATG, alemtuzumab but not IL-2RA was associated with worse long-term death-censored SPK graft outcome. Our analysis supports the common use of r-ATG for induction in US primary SPK recipients.

Immunosuppression for pancreas transplantation with an emphasis on antibody induction strategies: review and perspective

A review of recent literature was performed to identify trends and evaluate outcomes with respect to immunosuppression in pancreas transplantation (PTX). In the past decade, the majority of PTXs were performed with depleting antibody induction, particularly in the setting of either calcineurin inhibitor minimization, corticosteroid withdrawal or both. Maintenance immunosuppression consisted of predominantly tacrolimus (TAC)/mycophenolatemofetil, TAC/mycophenolic acid or TAC/sirolimus with or without corticosteroids. Depending on PTX category, donor and recipient risk factors, case mix and immunosuppressive regimen, the 1-year incidence of acute rejection has decreased to 5-20%. Current 1-year rates of immunological pancreas graft loss range between 1.8 and 6%. Depleting antibody induction and either TAC/mycophenolatemofetil or TAC/sirolimus maintenance therapy with early steroid withdrawal have become the mainstay of immunosuppression in PTX. However, the development of non-nephrotoxic, nondiabetogenic, and nongastrointestinal toxic regimens is highly desirable to improve quality of life in all solid organ transplant recipients.

Trends in immunosuppression after pancreas transplantation: what is in the pipeline?

PURPOSE OF REVIEW

To provide an overview of currently available immunosuppressive strategies and novel therapeutic developments in pancreas transplantation.

RECENT FINDINGS

From 1966 through 2012 more than 30 000 pancreas transplantations have been performed around the world with excellent patient and graft survival. However, drug-related side effects and toxicities remain to negatively affect long-term outcomes. At present, more than 90% of pancreas transplant recipients receive induction therapy with depleting or nondepleting antibodies. The most widely used maintenance protocols are based on tacrolimus and mycophenolate mofetil with early or delayed corticosteroid withdrawal. In case of documented side effects related to this standard protocol, several regimens are actively pursued to switch to mammalian target of rapamycin inhibitors as well as to attempt initial calcineurin inhibitor avoidance and immunosuppression minimization. In addition, the recent documented negative impact of donor-specific antibodies on pancreas transplantation outcome has resulted in new treatment protocols for antibody-mediated rejection including intravenous immunoglobulins, anti-CD20 antibodies and protease inhibitors.

SUMMARY

Implementation of novel therapeutic strategies and combination protocols to reduce or avoid drug toxicities and immune-related complications that are evaluated in prospective and randomized trials is requested to improve outcomes after pancreas transplantation.

Factors influencing outcome of simultaneous kidney and pancreas transplantation: a 23-year single-center clinical experience

INTRODUCTION

Simultaneous kidney and pancreas transplantation (SKPT) has become an effective treatment for patients who have diabetes mellitus type I with advanced nephropathy. This study assesses the progress of the SKPT program at Uppsala University Hospital, Sweden, and evaluates prognostic factors for graft survival.

MATERIALS AND METHODS

Between February 1986 and September 2009, we performed 113 SKPT. The immunosuppression protocols changed over time and are defined as era 1, cyclosporine (CyA), atzathioprine (AZA) and steroids (C/A/S); era 2, C/A/S with antithymocyte globulin (ATG) induction (C/A/S/A); era 3, CyA, mycophenolate mofetic (MMF), steroids and ATG induction (C/M/S/A); era 4, tacrolimus (TAC), MMF, steroid, and ATG induction (T/M/S/A) and era 5, TAC, MMF, steroids and basiliximab induction (T/M/S/B). We analyzed donor/recipient/operative and postoperative variables to assess their influence on pancreas graft and patient survivals.

RESULTS

The overall 1-, 5-, and 10-year patient survivals were 95.5%, 84.1%, and 65.5%, respectively. The 1-, 5-, and 10-year overall pancreas graft survivals were 77.6%, 58.4%, and 48.4%. The 1-, 5-, and 10-year pancreas graft survivals in SKPT patients transplanted between October 1997 and September 2009. (T/M/S/A and T/M/S/B; eras 4 and 5) were 95.3%, 72.7%, and 63.1%, respectively, which was significantly better than those of patients transplanted between February 1986 and September 1997 (era, 1 through 3) (P < 0.01, P < 0.0001, respectively). The quadruple regimen with TAC and MMF (eras 4 and 5) decreased the incidence of acute rejection episodes compared with eras 1 through 3 (P < 0.0001). Basiliximab induction (T/M/S/B; era 5) reduced the CMV infection rate compared with eras 1 through 4 (P < 0.01). Multivariate analysis revealed that donor age (younger than 40 years), immunosuppressive regimen with TAC and MMF (eras 4 and 5), and absence of acute rejection episodes independently affected pancreas graft survival.

CONCLUSIONS

We demonstrate a superiority of the quadruple protocol with T/M/S/B for graft and patient survival with a decreased incidence of CMV infection after SKPT.

Immunosuppression in simultaneous pancreas-kidney transplantation: progress to date

Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal failure due to type 1 diabetes mellitus. With advances in surgical techniques and immunosuppression management, outcomes have improved, with current 1- and 10-year pancreas graft survival rates of 86% and 53%, respectively. Induction therapy with either alemtuzumab or rabbit antithymocyte globulin (rATG) in combination with a calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) or sirolimus appears to be safe and effective in the setting of rapid steroid withdrawal (RSW), with excellent graft survival and low rejection rates. There are no large randomized trials between alemtuzumab and rATG to determine whether one is better than the other. Anti-interleukin (IL)-2 receptor antibody induction and no induction in combination with a CNI, MMF or sirolimus, and prednisone have demonstrated excellent graft survival rates but are associated with a higher incidence of acute rejection. The efficacy of anti-IL-2 receptor antibodies or no induction in the setting of RSW is unproven. Both of the CNIs, ciclosporin and tacrolimus, are effective in preventing acute rejection in SPKT recipients; however, pancreas allograft survival may be better with tacrolimus. MMF is more effective than azathioprine in preventing acute rejection. Sirolimus appears to be effective in preventing acute rejection, but the combination of sirolimus with a CNI may accentuate the nephrotoxicity of the CNI. RSW with induction therapy is safe and effective in SPKT recipients, but longer follow-up data on outcomes are needed. Recent analysis of registry data shows that most transplant centres are using an induction agent followed by a combination of tacrolimus, MMF and corticosteroids in SPKT recipients.

Advances in immunosuppression for pancreas transplantation

PURPOSE OF REVIEW

A review of current literature was performed to identify trends and evaluate outcomes with regard to clinical immunosuppression in pancreas transplantation.

RECENT FINDINGS

Through 2006, over 20 000 pancreas transplantations were performed in the US. Since 2000, the 1-year patient survival rates for the three pancreas transplantation categories--simultaneous pancreas-kidney, sequential pancreas after kidney, and pancreas alone--were 95-97% and the 1-year pancreas graft survival (complete insulin independence) rates were 85%, 78%, and 77%, respectively. One-year rates of rejection have steadily decreased and are currently in the 10-20% range depending on case mix and immunosuppressive regimen. At present, 88% of recipients receive antibody induction, 65% receive maintenance therapy with the tacrolimus/mycophenolate mofetil combination, and 40-50% undergo corticosteroid withdrawal without adverse consequences. Limited data with tacrolimus/sirolimus reveal excellent short-term outcomes, whereas initial attempts with calcineurin inhibitor avoidance or minimization are less promising.

SUMMARY

Antibody induction and either tacrolimus/mycophenolate mofetil or tacrolimus/sirolimus maintenance therapy with steroid withdrawal have become the mainstay of contemporary immunosuppression in clinical pancreas transplantation. The development of a nonnephrotoxic, nondiabetogenic, and nongastrointestinal toxic regimen, however, is highly desirable to improve outcomes and quality of life in recipients.