Abstract
The maintenance of patients with renal transplant typically involves two or more drugs to prevent rejection and prolong graft survival. The calcineurin inhibitors (CNI) are the most commonly recommended medicines in combinations with others. While immunosuppressive treatment regimens are well established, there is insufficient long-term effectiveness data to help guide future management decisions. The study analyzes the effectiveness of treatment regimens containing CNI after renal transplantation during 16 years of follow-up with real-world data from the Brazilian National Health System (SUS). This was a retrospective study of 2318 SUS patients after renal transplantion. Patients were propensity score-matched (1:1) by sex, age, type and year of transplantation. Kaplan–Meier analysis was used to estimate the cumulative probabilities of survival. A Cox proportional hazard model was used to evaluate factors associated with progression to graft loss. Multivariable analysis, adjusted for diabetes mellitus and race/color, showed a greater risk of graft loss for patients using tacrolimus plus mycophenolate compared to patients treated with cyclosporine plus azathioprine. In conclusion, this Brazilian real-world study, with a long follow-up period using matched analysis for relevant clinical features and the representativeness of the sample, demonstrated improved long-term effectiveness for therapeutic regimens containing cyclosporine plus azathioprine. Consequently, we recommend that protocols and clinical guidelines for renal transplantation should consider the cyclosporine plus azathioprine regimen as a potential first line option, along with others.
Highlights
Kidney transplantation is considered the optimal choice for the treatment of patients with advanced renal failure due to improved quality of life and life expectancy versus renal dialysis, and it is the most cost-effective option when compared to dialysis [1,2,3,4,5,6]
A total of 1159 pairs were combined by type of transplantation, sex, age and year of transplantation between the cyclosporine and tacrolimus groups
Of the 2318 patients included in the study, most (63.0%) were prescribed mycophenolate in combination with a calcineurin inhibitors (CNI), followed by azathioprine (29.0%)
Summary
Kidney transplantation is considered the optimal choice for the treatment of patients with advanced renal failure due to improved quality of life and life expectancy versus renal dialysis, and it is the most cost-effective option when compared to dialysis [1,2,3,4,5,6]. With respect to tacrolimus and cyclosporine, considered as key elements of any immunosuppressive regimen, a variety of studies compared their relative effectiveness and safety. Similar controversies exist in relation to the anti-proliferatives [10] as well as with sirolimus and everolimus [14,16,17]. This illustrates the fact that recommendations for the use of different immunosuppressive regimens are complex and influenced by the type of donor and other clinical factors including prior dialysis length of time, recipient age, and sex [7,18]
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