Revisiting maintenance immunosuppression in patients with renal transplant failure: early weaning of immunosuppression versus prolonged maintenance—systematic review and meta-analysis

Significant Long‐Term Prevention of High Sensitization After Kidney Allograft Failure by Maintaining Calcineurin Inhibitor‐Based Immunosuppression

“…IS maintenance might be associated with an increased risk of infections, malignancies, and cardiovascular or metabolic complications, even though controversial results were reported on this subject [18,23,26,[29][30][31]34]. No associations between IS maintenance and mortality, infection, or malignancy rates have been reported in recent publications [24,28,45]. In the present study, CNI-based IS maintenance was not associated with an overall increased risk of infectious or neoplastic complications.…”

“…Recently, Ferrari et al reported that IS continuation was associated with lower sensitization and a reduced "incompatible graft rate" increase 6 months after KAF [28]. In contrast with these results, a meta-analysis by Elgenidy et al failed to demonstrate a protective role of IS maintenance for more than 3 months against allosensitization after KAF, even though the "leave-one-out analysis" demonstrated that, excluding the work of Martin et al that did not observe a correlation between IS withdrawal and allosensitization, lower PRA levels were significantly associated with IS maintenance beyond 6 months after KAF [25,27].…”

“…There is growing attention toward the impact of sensitization to immunosuppression (IS) withdrawal after KAF. IS withdrawal is reported to be an independent risk factor for allosensitization, increased PRA, and donor-specific antibodies (DSA) development, irrespective of allograft nephrectomy [15][16][17][18][19][20][21][22][23][24][25][26][27][28]. The benefits of IS maintenance must be considered against the increased risk of complications associated with IS drugs [29][30][31].…”

Can We Predict Graft Intolerance Syndrome After Kidney Transplant Failure? External Validation of a Previously Developed Model

“…However, evidence to support this hypothesis is lacking. Recent studies showed that patients still experienced rejection episodes and sensitization despite the continued use of immunosuppressants beyond the first year after transplant failure (20,21) Prospective interventional trials are needed to compare the occurrence of graft intolerance between patients with different immunosuppressive treatment strategies. In the meantime, risks and benefits of a pre-emptive graft nephrectomy could be discussed individually with patients who have no prospect of a retransplantation in the near future and a high predicted risk of graft intolerance syndrome according to our model.…”

Clinical relevance of HLA-DQ eplet mismatch and maintenance immunosuppression with risk of allosensitization after kidney transplant failure

“…Maintaining patients on their immunosuppressive drugs after transplant failure may reduce the risk of HLA antibody development. Several single-center studies report a significant increase in the calculated panel reactive antibody (cPRA) of transplant candidates who reduced their immunosuppression after allograft failure ( Augustine et al, 2012 ; Casey et al, 2014 ; Nimmo et al, 2018 ; Lucisano et al, 2019 ); however, this finding has not been consistently reproduced in other studies ( Martin et al, 2021 ; Knoll et al, 2022 ; Elgenidy et al, 2023 ). Potential reasons for this discrepancy include heterogeneity in the study cohorts, lack of granular immunosuppression data capture, differences in the methodology of HLA antibody detection and the thresholds for defining the outcome of allosensitization, and variable consideration for HLA mismatches.…”