Effect of early versus delayed calcineurin inhibitor treatment on delayed graft function

Abstract

IN RENAL TRANSPLANTATION, there is some controversy regarding the impact of delayed graft function (DGF) on long-term outcome. DGF, which usually ranges between 10% and 50%, makes the management of patients more complex, hinders the diagnosis of rejection, prolongs hospital stay, increases the financial cost of transplantation, and reduces graft survival rates. Acute rejection occurs more frequently producing a negative impact on long-term graft survival. The risk factors for DGF are advanced donor age and prolonged cold ischemia time. The introduction of calcineurin inhibitors (CNI), either cyclosporine (CsA) or tacrolimus (Tac), as the mainstay of immunosuppression has significantly decreased acute rejection rates and improved 1-year renal transplant survival. However, a side effect of CNI, acute nephrotoxicity due to adverse hemodynamic effects, may increase the rate of DGF. Polyclonal antibodies (PCA)–antithymocyte (ATG) or antilymphocyte (ALG) sera used for induction therapy reduce the risk of acute rejection episodes, reverse steroidresistant rejection, and improve graft survival. The administration of PCA in sequential immunosuppression for patients afflicted with DGF reduces the incidence of first rejection episodes, although both graft and patient survivals are not statistically different. In this study, we compared a conventional immunosuppressive protocol of CNI and mycophenolate mofetil (MMF) plus steroids with CNI, MMF, steroids, and PCA in renal transplants with delayed graft function.