Immunosuppression for Long-Term Maintenance of Renal Allograft Function

Synthesis of chiral propargyl alcohols following the base-induced elimination protocol: application in the total synthesis of natural products

Synthesis of enantiomerically pure propargyl alcohols is one of the most important tools in organic synthesis and “base-induced elimination of β-alkoxy chlorides” could offer the enantiomerically pure propargyl alcohols.

Pediatric renal transplant biopsy with ultrasound guidance: the 'core' essentials

This review provides a comprehensive and practical approach to pediatric percutaneous renal transplant biopsies, highlighting techniques and strategies to optimize adequate sample yield and ensure patient safety. In children with end-stage renal disease, transplantation is the preferred choice of therapy, providing for overall lower long-term morbidity and mortality compared with dialysis. In the ongoing management of renal transplant patients, core tissue sampling via a percutaneous renal biopsy remains the gold standard when transplant dysfunction is suspected. Indications for renal transplant biopsy and techniques/tools for adequate sample yield are discussed. Strategies for common challenges such as poor visualization and renal transplant mobility are addressed. We discuss the clinical signs, techniques and imaging findings for common complications including hematomas, arteriovenous fistulas and pseudoaneurysms. Although the percutaneous renal transplant biopsy procedure is generally safe with rare complications, care must be taken to ensure major complications are promptly recognized and treated. Adequate tissue samples obtained via renal biopsy are imperative to promptly identify transplant rejection to provide valuable information for patient diagnosis, treatment and outcomes. Radiologist and nephrologist attention to proper ultrasound techniques and optimal biopsy tools are critical to ensure tissue adequacy and minimize complications.

Clinical risk factors associated with the post-transplant anemia in kidney transplant patients

BACKGROUND

Anemia is a very common occurrence in post-renal transplant patients. Post-transplantation anemia (PTA) is associated with significant graft loss or cardiovascular morbidity. The objective of this study is to identify clinical risk factors associated with anemia after kidney transplantation.

METHODS

Our retrospective cohort study included a total of 570 renal transplant recipients. For the definition of anemia, we adopted "the lower limit of normal for Hgb concentration of blood" proposed by Beutler E and Waalen J [14], which has adjustments for age, gender and ethnicity. Post-transplant anemia (PTA) was defined as anemia that arose between 30 and 180days after transplantation. Based on this definition, of the 570 renal transplant recipients, 344 patients (62.1%) experienced PTA. The patients were divided into anemic and non-anemic groups, and a total of 20 clinical factors were compared between the two groups.

RESULTS

In the univariate analysis, age, race, multiple transplants, delayed graft function (DGF), and use of tacrolimus, sirolimus, thymoglobulin, ganciclovir, ACE inhibitors, and ARBs were associated with PTA. In the multivariate analysis, age (>60years old, OR=2.62, p=0.001), race (OR=2.54, p=0.001), and use of sirolimus (OR=2.01, p=0.019), antiviral agents (OR=1.96, p=0.015), thymoglobulin (OR=1.86, p=0.011), and DGF (OR=2.78, p=0.001) remained significant.

CONCLUSION

The current results show that undergoing a transplant at age 60 or older, use of sirolimus, antiviral agents, and thymoglobulin are independent clinical risk factors associated with PTA. In terms of ethnicity, AA, MEA, or PI is higher risk for PTA and Hispanic is significantly lower risk for PTA compared to Caucasians.

Tanshinol suppresses cardiac allograft rejection in a murine model

BACKGROUND

Achieving long-term cardiac allograft survival without continuous immunosuppression is highly desired in organ transplantation. Studies have shown that Salvia miltiorrhiza, an herb also known as danshen, improves microcirculation and is highly effective in treating coronary heart disease. Our objective is to determine whether tanshinol, an ingredient of danshen, improves cardiac allograft survival.

METHODS

Fully vascularized heterotopic heart transplantation was performed using BALB/c mice as donors and C57BL/6 mice as recipients, which were then treated with tanshinol and rapamycin. CD4⁺FoxP3⁺ regulatory T cells (Tregs) were quantified by flow analyses, whereas CCL22 was measured by real-time polymerase chain reaction and Western blotting.

RESULTS

We found that tanshinol significantly delayed cardiac allograft rejection. It promoted long-term allograft survival induced by rapamycin, a mammalian target-of-rapamycin (mTOR) inhibitor. Tanshinol increased CD4⁺FoxP3⁺ Treg numbers in cardiac allografts, but not spleens and lymph nodes, of recipient mice by enhancing chemokine CCL22 expression in cardiac allografts, especially cardiac dendritic cells. In contrast, rapamycin increased Treg numbers in both lymphoid organs and allografts, suggesting that it generally expands Tregs. Moreover, Tregs induced by rapamycin plus tanshinol were more potent in suppressing T-cell proliferation in vitro than those from untreated recipients. Neutralizing CCL22 hindered CD4⁺FoxP3⁺ Treg migration to cardiac allografts and reversed long-term allograft survival induced by tanshinol plus rapamycin.

CONCLUSIONS

Tanshinol suppresses cardiac allograft rejection by recruiting CD4⁺FoxP3⁺ Tregs to the graft, whereas rapamycin does so via expanding the Tregs. Thus, tanshinol cooperates with rapamycin to further extend cardiac allograft survival.

Sustained renal response to mycophenolate mofetil and CNI taper promotes survival in liver transplant patients with CNI-related renal dysfunction

AIM

The aim of this trial was to evaluate the impact of conversion from a calcineurin-inhibitor (CNI)-based immunosuppressive regimen to mycophenolate mofetil (MMF) and reduced-dose CNI on long-term renal function and survival in a series of 63 liver transplant patients with CNI-induced renal dysfunction.

METHODS

CNI dosage was significantly tapered after introduction of 2,000 mg MMF per day. Renal function was assessed by determination of serum creatinine levels and calculated creatinine clearance (CCl). The impact of relevant clinical parameters on renal function and survival post-conversion was analyzed by univariate and multivariate analysis.

RESULTS

At 60 months post-conversion, mean creatinine level had significantly declined from 197.2±58.3 μmol/l at baseline to 160.0±76.5 μmol/l, and mean CCl has significantly increased from 38.4±13.4 ml/min at baseline to 47.9±21.1 ml/min (p<0.001), respectively. Forty-six patients (73.1%) demonstrated sustained renal response to modified immunosuppression. Full-dose MMF medication (p=0.006) and the early conversion (p=0.02) were identified as independent predictors of persistent renal function improvement. Sustained renal response to MMF plus reduced-dose CNI was identified as the most relevant independent promoter of long-term survival (hazard ratio 6.9). Five-year survival rate post-conversion was 93.9% in renal responders and 64.3% in renal non-responders (log rank<0.001).

CONCLUSIONS

Sustained renal response to MMF and CNI dose reduction promotes long-term survival in liver transplant patients with CNI-induced renal dysfunction.

Incidence and clinical predictors of primary opportunistic deep cutaneous mycoses in solid organ transplant recipients: a multicenter cohort study

BACKGROUND

Primary opportunistic deep cutaneous fungal infections may cause significant morbidity and mortality in solid organ transplant recipients (OTR), but no data exist about their incidence, timing, and clinical predictors in a long-term follow-up.

PATIENTS AND METHODS

A series of 3293 consecutive OTR including 1991 kidney, 929 heart, and 373 liver transplant recipients were enrolled. Patients were regularly followed up since time at transplantation (mean 5.5 yr +/-5.9 SD) and primary opportunistic fungal infections registered. Persons-year at risk (PYs), incidence rates (IR), incidence rate ratios (IRR), and 95% confidence intervals were computed.

RESULTS

Twenty-two cases of deep cutaneous mycoses were detected, (IR 1.2 cases per 1000 PYs) after a mean follow-up time since transplantation of 2.5 yr +/- 2.0 SD (median 1.8 yr). Six patients had subsequent systemic involvement and three patients died of systemic dissemination. A higher risk for mycoses was observed in the first two yr after transplantation, (IRR 35.9, p < 0.0001), in renal transplant recipients (IRR 5.1 p = 0.030), and in patients transplanted after the age of 50 (IRR 11.5 p = 0.020).

CONCLUSIONS

Primary deep cutaneous opportunistic mycoses in OTR occur mainly in the first two yr after transplantation, in renal transplant recipients, and in older patients.

Geranylated flavonoids from the roots of Campylotropis hirtella and their immunosuppressive activities

In an effort to identify new immunosuppressive agents from natural sources, 12 new geranylated flavonoids, 5,7,4'-trihydroxy-3'-[7-hydroxy-3,7-dimethyl-2(E)-octenyl]isoflavone (1), a racemate of 5,7,2',4'-tetrahydroxy-3'-[7-hydroxy-3,7-dimethyl-2(E)-octenyl]isoflavanone (2), 2''(S)-5,7-dihydroxy-[2''-methyl-2''-(4-methyl-3-pentenyl)pyrano]-5'',6'':3',4'-isoflavone (3), (2''S,3''R,4''S)-5,7,3'',4''-tetrahydroxy[2''-methyl-2''-(4-methyl-3-pentenyl)pyrano]-5'',6'':3',4'-isoflavone (4), a racemate of 3'-geranyl-5,7,2',4'-tetrahydroxyisoflavanone (5), a racemate of 3'-geranyl-4'-methoxy-5,7,2'-trihydroxyisoflavanone (6), 3'-geranyl-5,7,4',5'-tetrahydroxyisoflavone (8), 3'-geranyl-5,7,2',5'-tetrahydroxyisoflavone (9), 3'-geranyl-4'-methoxy-5,7,2'-trihydroxyisoflavone (10), 2(R),3(R)-3'-geranyl-2,3-trans-5,7,4'-trihydroxyflavonol (12), (2R,3R)-6-methyl-3'-geranyl-2,3-trans-5,7,4'-trihydroxyflavonol (13), and 5,7-dihydroxy-4'-O-geranylisoflavone (14), were isolated from the roots of Campylotropis hirtella (Franch.) Schindl. together with three previously described flavonoids. Their structures were elucidated by spectroscopic measurements, including two-dimensional nuclear magnetic resonance (NMR) techniques. The immunosuppressive effects of these compounds were assessed using mitogen-induced splenocyte proliferation, and the cytotoxicity of the compounds was also examined. The IC50 values of the compounds were found to be in the range of 1.49-61.23 microM for T lymphocyte suppression and 1.16-73.07 microM for B lymphocyte suppression. An analysis of their structure-activity relationships revealed that an isoflavonoid carbon skeleton with a C10 substituent at the C3' position was necessary for the activity. As many of the compounds exhibited good immunosuppressive activities, they may be promising as novel immunosuppressive agents.

Cost-effectiveness of a new combined immunosuppressive and anti-infectious regimen in kidney transplantation

Objectives:The aims of this study were to assess the 1-year cost-effectiveness of a new combined immunosuppressive and anti-infectious regimen in kidney transplantation to prevent both rejection and infectious complications.

Methods:Patients (pts) transplanted from January 2000 to March 2003 (Group A) and treated with a conventional protocol were compared with pts submitted to a combined regimen including universal cytomegalovirus (CMV) prophylaxis between April 2003 and July 2005 (Group B). Costs were computed from the hospital accounting system for hospital stays, and official tariffs for outpatient visits. Patients with incomplete costs data were excluded from analysis.

Results:Fifty-three patients were analyzed in Group A, and 60 in Group B. Baseline characteristics including CMV serostatus were not significantly different between the two groups. Over 12 months after transplantation, acute rejections decreased from 41.5 percent in Group A to 6.7 percent in Group B (p&lt; .001), and CMV infections from 47 percent to 15 percent (p&lt; .001). Overall, readmissions decreased from 68 percent to 55 percent (p= .160), and average hospital days from 28 ± 19 to 20 ± 11 days (p&lt; .007). The average number of outpatient visits decreased from 49 ± 10 to 39 ± 8 (p&lt; .001). Average 1-year immunosuppressive and CMV prophylaxis costs (per patient) increased from CHF20,402 ± 7,273 to 27,375 ± 6,063 (p&lt; .001), graft rejection costs decreased from CHF4,595 ± 10,182 to 650 ± 3,167 (p= .005), CMV treatment costs from CHF2,270 ± 6,161 to 101 ± 326 (p= .008), and outpatient visits costs from CHF8,466 ± 1’721 to 6,749 ± 1,159 (p&lt; .001). Altogether, 1-year treatment costs decreased from CHF39’957 ± 16,573 to 36,204 ± 6,901 (p= .115).

Conclusions: The new combined regimen administered in Group B was significantly more effective, and its additional costs were more than offset by savings associated with complications avoidance.

Leishmaniasis among organ transplant recipients

Leishmaniasis is a rarely reported disease among transplant recipients; however, the number of published cases has quadrupled since the beginning of the 1990s. Most cases have been observed in patients living in countries of the Mediterranean basin. Leishmaniasis is most commonly associated with kidney transplantation (77%), and cases are also recorded among patients undergoing liver, heart, lung, pancreas, and bone marrow transplantation. Visceral leishmaniasis (VL) is the most frequently observed clinical presentation, followed by mucosal leishmaniasis and more rarely cutaneous leishmaniasis. Transplant recipients with VL develop the classic clinical form of the disease, which is a febrile hepatosplenic and pancytopenic syndrome. Immunodepression seems to predispose to development of mucosal leishmaniasis caused by viscerotropic strains. Early diagnosis of VL is crucial for patient therapy and outcome; however, this is frequently overlooked or delayed in transplant patients. Pentavalent antimonials are the most commom form of treatment for VL, but have a high incidence of toxicity (34%). Although used in fewer patients, liposomal amphotericin B seems to be better tolerated and should be considered as first-line therapy in transplant recipients.

The immunology of composite tissue transplantation

Composite tissue allotransplantation holds great potential for reconstructive surgery. That these procedures can be successful has been clearly demonstrated by the success of hand, face, and larynx transplants around the world. Although the immunology of composite tissue allotransplantation mirrors that of any allogeneic organ transplant, there are several unique aspects to these grafts. This article reviews the immunology of transplantation, histocompatibility testing for composite tissue allotransplantation, graft rejection, immunosuppression, and specific immunologic considerations of composite tissue allotransplantation.

Tacrolimus in the treatment of idiopathic nephrotic syndrome

The immunosuppressant tacrolimus (FK-506) is a calcineurin inhibitor with a widespread use for the prevention of graft rejection in transplantation medicine. Tacrolimus inhibits the activation of an essential transcription factor for the transcription of cytokine genes in T cells leading to a decreased production of cytokines such as IL-2 and IFN-gamma. As T-cell activation plays a crucial role in the pathogenesis of inflammatory glomerular diseases, there is an increasing number of reports on the use of tacrolimus in nephrotic syndrome. In idiopathic nephrotic syndrome, corticosteroid treatment constitutes the first-line therapy to achieve remission. In the case of steroid resistance or steroid dependence, alternative immunosuppressive strategies are needed. Cyclophosphamide and ciclosporin are well-established drugs in this condition. The present article reviews the pharmacodynamics, pharmacokinetics, safety and clinical efficacy of tacrolimus in steroid-resistant and steroid-dependent nephrotic syndrome.

Corticosteroids influence the mortality and morbidity of acute critical illness

INTRODUCTION

Use of corticosteroids for adrenal supplementation and attenuation of the inflammatory and immune response is widespread in acute critical illness. The study hypothesis was that exposure to corticosteroids influences the mortality and morbidity in acute critical illness.

METHODS

This case-control retrospective study was performed in a single multidisciplinary intensive care unit at a tertiary care institution and consisted of 10,285 critically ill patients admitted between 1 January 1999 and 31 December 2004. Demographics, comorbidities, acute illness characteristics including severity measured by Sequential Organ Failure Assessment, concurrent medications, therapeutic interventions and incidence of infections were obtained from electronic medical records, were examined with multiple regression analysis and were adjusted for propensity of corticosteroid exposure. The primary outcome was hospital death, and the secondary outcome was transfer to a care facility at hospital discharge.

RESULTS

Corticosteroid exposure in 2,632 (26%) patients was characterized by younger age, more females, higher Charlson comorbidity and maximal daily Sequential Organ Failure Assessment scores compared with control patients. Corticosteroids potentiated metabolic and neuromuscular sequels of critical illness with increased requirements for diuretics, insulin, protracted weaning from mechanical ventilation, need for tracheostomy and discharge to a care facility. Early exposure to corticosteroids predisposed to recurrent and late onset of polymicrobial and fungal hospital-acquired infections. Corticosteroids increased the risk for death or disability after adjustments for comorbidities and acute illness characteristics.

CONCLUSION

Corticosteroids increased the risk for death or disability in critical illness. Hospital-acquired infections and metabolic and neuromuscular sequels of critical illness were exacerbated by corticosteroids. Careful appraisal of the indications for use of corticosteroids is necessary to balance the benefits and risks from exposure in acute critical illness.

Anemia After Renal Transplantation

Anemia in the setting of chronic kidney disease is a well-recognized phenomenon that is associated with decreasing renal function and deficiency of or resistance to erythropoietin. However, anemia in the post-renal transplantation setting has received comparatively less attention in the literature. In this review, we aim critically to appraise the available literature regarding posttransplantation anemia, concentrating in particular on the prevalence of posttransplantation anemia, its etiopathogenesis, potential effects on morbidity and mortality, and the rationale for intervention and treatment. Despite deficiencies in the literature, we conclude that posttransplantation anemia is a common phenomenon that can occur either early or late posttransplantation, and its causation is usually multifactorial and includes contributions notably from poor or decreasing renal function, immunosuppression, and iron deficiency. Conversely, there is a shortage of well-conducted prospective studies looking at the morbidity attributable to posttransplantation anemia and a lack of trial evidence to determine whether intervention improves patient morbidity and outcome.

Mycophenolate mofetil in organ transplantation: focus on metabolism, safety and tolerability

Mycophenolate mofetil (MMF) received its first approval for the prevention of renal allograft rejection in 1995 and has now become the most frequently used antiproliferative agent in maintenance immunosuppressive therapy for kidney, pancreas, liver and heart transplantation. In addition, its use for the treatment of autoimmune diseases steadily increases. This review focuses on the miscellaneous pharmacodynamic properties of the drug, its pharmacokinetics in healthy subjects, recipients of different organ transplants and combination therapy with other pharmaceuticals, as well as its safety profile. The immunosuppressive activity of MMF is thought to derive mainly from the potent and selective inhibition of purine synthesis in both T and B lymphocytes. In contrast to other immunosuppressants on the market, it is metabolised primarily by glucuronidation and lacks nephrotoxicity, cardiovascular toxicity or diabetogenic potential, thus making it a suitable candidate for combination regimens. The most important side effects under MMF include gastrointestinal disorders, of which the underlying mechanisms are not yet fully understood, but seem to be complex and related to both effects of mycophenolic acid and its acyl glucuronide, as well as to decreased -immunity due to general immunosuppression after transplantation.

Posttransplantation Anemia in Adult Renal Allograft Recipients: Prevalence and Predictors

BACKGROUND

Management of anemia is an important factor in the care of patients with chronic kidney disease as the anemic state can confer significant morbidity and mortality. Posttransplantation anemia (PTA) has received comparatively less attention in the literature, and the prevalence and predictors of PTA vary between different studies. The purpose of this study was to investigate a large posttransplant population from 3 centres in the UK to elucidate the point prevalence of PTA, its determinants and the use of erythropoiesis stimulating agents (ESA) in these patients.

METHODS

All adult patients with functioning renal transplants and attending renal transplant outpatients at Guy's, King's College, or St. Helier Hospitals, London, as of 31/12/2004 who had a valid hemoglobin in the previous 3 months, and who were more than 3 months postengraftment, were identified. Patients' notes and electronic patient records were obtained and a detailed cross-sectional clinical and biochemical database was constructed. The data were analyzed for the point prevalence of PTA, the prevalence of ESA use and for determinants of hemoglobin. The WHO criteria were used to define anemia and all patients on treatment with an ESA was classified as anemic irrespective of hemoglobin.

RESULTS

A total of 1,511 (947 male) patients were studied. Mean age was 48.1+/-13.7 years with no difference between the sexes. Mean time posttransplantation was 8.5+/-7.2 years and mean estimated MDRD GFR was 47.6+/-18.9 ml/min with a higher GFR in males (49.9+/-19.0 v 43.8+/-18.0 mL/min, P<0.0001). Mean hemoglobin in the studied population was 12.9+/-1.6 g/dl with a significantly higher level among males than females (mean 13.3+/-1.6 v 12.3+/-1.4 g/dl, P<0.0001). The prevalence of anemia was 45.6% with a prevalence of 44.1% among males and 48.1% amongst females. Severe anemia was present in 50 subjects (3.3% of the total cohort). One hundred and forty-five patients (9.6% of the entire cohort) were being treated with an ESA. Of these subjects, 41 did not meet WHO criteria for the definition of anemia. After multiple regression analyses, age, female sex, renal function and to a lesser extent serum ferritin and therapy with angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (both negatively associated) were predictive of hemoglobin.

CONCLUSIONS

The prevalence of anemia posttransplantation was high while comparatively few patients were being treated with erythropoiesis stimulating agents. The strongest predictors of hemoglobin in this cohort of patients were age, female sex and allograft function. Medical therapy with MMF and sirolimus was associated with a high prevalence of anemia but this was likely to be the result of poorer graft function in these subjects who mostly had chronic allograft nephropathy. A large interventional prospective study with valid control groups is now needed to assess the long-term contributions of clinical and biochemical factors of renal function and to elucidate the effects of therapy on outcome.

A novel artemisinin derivative, 3-(12-beta-artemisininoxy) phenoxyl succinic acid (SM735), mediates immunosuppressive effects in vitro and in vivo

AIM

To study the immunosuppressive activity of SM735 {[3-(12-beta-artemisininoxy)] phenoxyl succinic acid}, a synthetic artemisinin derivative with nonsteroidal anti-inflammatory drug structure, with the aim of finding potential immunosuppressive agents.

METHODS

Concanavalin A (ConA), lipopolysaccharide (LPS), and mixed lymphocyte reaction (MLR), were used to induce the proliferation of splenocytes, and [3H]-thymidine incorporation was used to evaluate the proliferation of splenocytes. Cytokine production was promoted with ConA, LPS, or PMA plus ionomycin, and was detected with the enzyme-linked immunosorbent assay. Dinitrofluorobenzene (DNFB) and sheep red blood cells (SRBC) were used to induce delayed-type hypersensitivity and quantitative hemolysis of SRBC (QHS) mouse models, as criteria for the evaluation of in vivo immune activity.

RESULTS

SM735 strongly inhibited the proliferation of splenocytes induced by ConA, LPS, or MLR, with IC(50) values of 0.33 micromol/L, 0.27 micromol/L, and 0.51 micromol/L, respectively. When compared with a CC(50) value of 53.1 micromol/L, SM735 had a favorable safety range. SM735 dose-dependently inhibited proinflammatory cytokine production [including interleukins (IL)-12, interferon (IFN)-gamma and IL-6] induced by LPS or PMA plus ionomycin. Upon ConA stimulation, SM735 suppressed IFN-gamma in a dose-dependent manner, but did not affect IL-2 secretion. SM735 also strongly suppressed both T-cell-mediated delayed-type hypersensitivity (DTH) and B-cell-mediated QHS reactions.

CONCLUSION

SM735 had strong immunosuppressive activity in vitro and in vivo, suggesting a potential role for SM735 as an immunosuppressive agent, and established the groundwork for further research on SM735.

Chronic allograft nephropathy

PURPOSE OF REVIEW

Chronic allograft nephropathy is the major cause of late renal allograft loss. This disease is heterogeneous and the diagnosis is nonspecific, with both immune and nonimmune causes. Increasingly, we are able to recognize specific contributors to the disease.

RECENT FINDINGS

Further understanding of chronic allograft nephropathy comes from a large study detailing the natural history of the disease, from protocol biopsies revealing subclinical cellular rejection, and from studies using C4d staining to distinguish antibody-mediated chronic rejection from nonspecific causes. Also made more clear are nonimmune mechanisms of chronic allograft nephropathy, such as the effect of decreased dosing of calcineurin inhibitors, and the concept of senescence as a mechanism of the disease.

SUMMARY

Chronic allograft nephropathy is a heterogeneous disease with immune and nonimmune causes. Some features recognizable by histology and detected by other laboratory tests can help to categorize specific causes of the disease in particular cases. In addition, recent studies have contributed to our knowledge of the pathogenesis of the disease. In order to advance our understanding, we must be able to distinguish the various recognizable causes of chronic allograft dysfunction. Further research is warranted on the subset of the disease with indeterminate cause.

Steroid-free immunosuppression in organ transplantation

Although steroids have been the cornerstone of immunosuppressive regimens to treat and prevent rejection in organ transplantation, the past decade has seen many successful attempts to minimize or eliminate steroid use. This has been undertaken to decrease the diverse side effects seen with chronic steroid treatment. These efforts have focused on both steroid avoidance and complete elimination, and have been successful across broad patient groups. The key to these efforts has been the adoption of induction protocols with either lymphocyte-depleting agents or anti-interleukin-2 strategies, coupled with the use of the newer maintenance immunosuppressants. In this review, we address the feasibility and benefits of steroid-free and steroid avoidance protocols in kidney, pancreas, liver, and heart transplantation.

Immunosuppression With Antithymocyte Globulin in Renal Transplantation: Better Long-Term Graft Survival

We analyzed the impact of antithymocyte globulin (ATG) in renal transplantation. We retrospectively studied 1217 recipients performed from July 83 to December 03. ATG-Fresenius-S (ATG-F) was used for induction therapy in 492 patients (40.4%; group I) and compared with group II, 725 patients (59.6%), without antilymphocyte induction. Groups were comparable in terms of recipient gender and race distribution; time on dialysis; cause of renal disease; number of human leukocyte antigen (HLA) mismatches; donor age, gender, and creatinine; and cold ischemia time. Patients with ATG-F were younger (35.8 +/- 13.8 vs 38.9 +/- 12.5 years, P < .001), more frequently hypersensitized (10% vs 3%, P < .001), and had more second transplants (15.7% vs 5.8%, P < .001). The incidence of acute rejection episodes was lower among ATG-F patients (23.6% vs 32.1%, P = .004). Admission time and incidence of delayed graft function (DGF) were similar in the two groups. Graft survival at 1, 5, 10, and 15 years was 88.9%, 80.7%, 71.3%, and 64.9% in group I and 86.4%, 77.4%, 60.7%, and 48.4% in group II (P = .003). The difference in patient survival over the same follow-up did not reach statistical significance. Multivariate analysis showed that the risk of graft failure was higher for those who did not receive ATG-F (HR = 1.51; 95% CI, 1.14 to 2.00; P = .004). Donor age and DGF were also independent predictors of graft failure. Our results showed a better long-term graft survival among patients who received ATG-F, despite their higher immunological risk. The absence of induction with ATG-F, donor age, and DGF were independent risk factors for graft failure.