Outcome at 3 Years with a Prednisone-Free Maintenance Regimen: A Single-Center Experience with 349 Kidney Transplant Recipients

Khwaja, Khalid; Asolati, Michele; Harmon, James V.; Melancon, J. Keith; Dunn, Ty B.; Gillingham, Kristen J.; Kandaswamy, Raja; Humar, Abhinav; Gruessner, Rainer W.G.; Payne, William D.; Najarían, John S.; Dünn, David L.; Sutherland, David E.R.; Matas, Arthur J.

doi:10.1111/j.1600-6143.2004.00443.x

Cited by 94 publications

(60 citation statements)

References 41 publications

(54 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Another interesting question is why late withdrawal of prednisone is associated with an increased incidence of rejection (6-10), yet prednisone avoidance or rapid elimination is not (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). One possible explanation is that most prednisone avoidance trials use perioperative antibody.…”

Section: Discussionmentioning

confidence: 99%

“…The MMF dose was adjusted for gastrointestinal side effects (nausea, vomiting, or diarrhea) or bone marrow suppression. Management of leukopenia has been described in detail previously (21). CSA was started at 8 mg/kg/day (in two divided doses) and adjusted to achieve levels of 150-200 lg/L (by high-performance liquid chromatography [HPLC]) for the first 3 months.…”

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

A Prospective Randomized Trial of Steroid-Free Maintenance Regimens in Kidney Transplant Recipients—An Interim Analysis

Kandaswamy

Melancon

Dunn

et al. 2005

American Journal of Transplantation

Self Cite

100

View full text Add to dashboard Cite

We compared three maintenance immunosuppressive regimens in a rapid discontinuation of prednisone protocol. From March 1, 2001, through December 31, 2003, 239 first and second kidney transplant recipients (166 LD; 73 DD) were randomized. All recipients were treated with Thymoglobulin; all received steroids intraoperatively and for 5 days postoperatively. Randomization was to cyclosporine-mycophenolate mofetil (n = 85); high-level tacrolimus (TAC) (8-12 ng/mL)-low-level sirolimus (SRL) (3-7 ng/mL) (n = 72); or lowlevel TAC (3-7 ng/mL)-high-level SRL (8-12 ng/mL) (n = 82). We found no difference at 24 months between groups in patient, graft, death-censored graft, or acute rejection-free graft survival, or in kidney function.Wound complications were more common in SRLtreated recipients (p = 0.02); we found no other differences between groups in complication rates. Our data suggest that excellent patient and graft survival and low rejection rates can be obtained using a variety of maintenance protocols without prednisone.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

A Prospective Randomized Trial of Steroid-Free Maintenance Regimens in Kidney Transplant Recipients—An Interim Analysis

Kandaswamy

Melancon

Dunn

et al. 2005

American Journal of Transplantation

Self Cite

100

View full text Add to dashboard Cite

show abstract

“…24 It inhibits growth of human EBV-transformed B lymphocytes and has been used successfully in the treatment of PTLD. [24][25][26][27] There is also a report of PTLD regressing with interferon-␣ therapy. 28 Chemotherapy is the most common treatment offered to patients with aggressive or late PTLD with features of monoclonal lymphomas.…”

Section: Discussionmentioning

confidence: 99%

Late occurrence of malignant post‐transplant lymphoproliferative disorder (PTLD) presenting with severe acute renal failure

Ziari¹,

Kudva²,

Salinas-Madrigal³

et al. 2007

Dialysis & Transplantation

View full text Add to dashboard Cite

Post-transplant lymphoproliferative disorder (PTLD) is a serious complication of solid organ transplantation. It occurs in 1% of kidney transplants. More than 80% of the incidences of PTLD occur within the first year after transplant. The most common risk factors for PTLD include Epstein-Barr virus (EBV) infection and the degree and type of immunosuppression. 1,2 We report a case of a patient who presented with PTLD with severe acute renal failure 17 years after kidney transplantation. He had an excellent response to the chemotherapy regimen and remained in remission for 6 months, before he was found to have recurrence of the disease in his cervical lymph nodes. The patient refused further chemotherapy and died after a month with normal renal function. Case ReportA 63-year-old male farmer with a history of end-stage renal disease secondary to poststreptococcal glomerulonephritis received a renal transplant of a kidney from a living related donor, his daughter, in 1988. The patient was on oral prednisone 5 mg daily and cyclosporine 125 mg twice daily for maintenance immunosuppressive therapy. His graft function was stable, with a serum creatinine of 1.1 mg/dL. Seventeen years after transplantation, he presented to his primary care physician with low back pain, generalized fatigue, and nausea. He received oxycodone and acetaminophen/hydrocodone for presumed muscle spasm. The patient noticed right groin pain after a few days. His serum creatinine concentration had increased from 1.1 mg/dL, 7 months earlier, to 6.4 mg/dL. The patient had not received NSAIDs or ACE inhibitors. The patient received intravenous fluid for presumed dehydration. There was no improvement in renal function, and the patient was transferred to our hospital for further evaluation. His cyclosporine level was 162 ng/mL on admission and gradually trended down as it was held.The patient underwent acute hemodialysis. A kidney biopsy was performed to rule out acute allograft rejection. The biopsy revealed a dense cellular infiltrate that spread apart residual renal tubules and glomeruli. The infiltrate was relatively monomorphic and was composed predominantly of large atypical lymphoid cells with irregular nuclei, variable nucleoli, frequent mitoses, and variable quantities of amphophilic cytoplasm ( Figure 1A).Immunohistochemical staining was positive for CD20, CD79a, and Bcl-2 and negative for Kappa, Lambda, and Bcl-6 ( Figure 1B, C). The histology and immunohistochemical studies were consistent with the diagnosis of monomorphic PTLD-large B-cell lymphoma. Fluorescence in situ hybridization (FISH) revealed that the vast majority of cells were of male origin, consistent with recipient-derived tumor cells.Serum antibody titers to EBV capsid (IgG) was positive at 10.3, and to EBV early D Ag was positive at 3.41. EBV Nucl AG IgG and EBV capsid IgM were negative. EBV PCR was positive. CMV PCR and antigenemia were not tested for. Bone marrow aspiration and biopsy did not show any evidence of malignant lymphoma. A staging CT scan of the neck, chest, and ...

show abstract

“…A number of studies have been conducted in North American centers in both adults and children and in patients with simultaneous kidney and pancreas transplant recipients who have reported short-term efficacy and safety of rapid withdrawal of corticosteroids after transplantation (47)(48)(49)(50)(51)(52)(53)(54)(55)(56). Although excellent 1-yr graft and patient survivals have been reported in each of these studies, it is noteworthy that rejection rates are for the most part higher with steroid elimination versus controls on steroids.…”

Section: Corticosteroid Avoidancementioning

confidence: 99%

Minimizing Immunosuppression, an Alternative Approach to Reducing Side Effects

Srinivas¹,

Meier‐Kriesche²

2008

Clinical Journal of the American Society of Nephrology

122

View full text Add to dashboard Cite

Exceptionally low acute rejection rates and excellent graft survival can be achieved with cyclosporine and tacrolimus (CNI)-based immunosuppressive protocols that incorporate antiproliferative immunosuppressants and corticosteroids. However, despite short-term success, long-term attrition of graft function and side effects of immunosuppressive agents continue to be significant problems, leaving clinicians looking for possible interventions. CNI nephrotoxicity is but one of numerous factors that may contribute to long-term damage in transplant kidneys. Metabolic, cosmetic, and neuropsychiatric complications of steroids affect quality of life after transplantation. Newer immunosuppressive agents such as mycophenolate mofetil and sirolimus (Rapa) have raised the possibility of withdrawing or avoiding CNIs or steroids altogether. In this report we review studies that address either CNI or steroid minimization strategies and discuss their risks versus benefits. Given the accumulated experience to date, in our opinion the use of CNIs and steroids as part of immunosuppressive regimens remains the proven standard of care for renal transplant patients. The long-term safety and efficacy of CNI and steroid minimization strategies needs to be further validated in controlled clinical trials with adequate long-term follow-up.

show abstract

Outcome at 3 Years with a Prednisone-Free Maintenance Regimen: A Single-Center Experience with 349 Kidney Transplant Recipients

Cited by 94 publications

References 41 publications

A Prospective Randomized Trial of Steroid-Free Maintenance Regimens in Kidney Transplant Recipients—An Interim Analysis

A Prospective Randomized Trial of Steroid-Free Maintenance Regimens in Kidney Transplant Recipients—An Interim Analysis

Late occurrence of malignant post‐transplant lymphoproliferative disorder (PTLD) presenting with severe acute renal failure

Minimizing Immunosuppression, an Alternative Approach to Reducing Side Effects

Contact Info

Product

Resources

About