Abstract
Introduction: Multiple investigators have demonstrated excellent results with ESW in low-risk RARs (low panel reactive antibody [PRA] Caucasians undergoing first transplant with immediate graft function [IGF]). However, AAs are considered a high-risk subgroup, with higher reported rates of acute and chronic rejection and graft loss. As a result, there has been a greater reluctance to use ESW in this population and very few reports with at least one-year follow-up in all patients (pts). Methods: We examined the outcomes of 57 adult AA RARs transplanted from 6/22/03 to 6/29/05 receiving ESW, with minimum and mean follow-up 12 and 23 ± 8 months (mo), respectively. Only pts who were on prednisone at the time of transplant or had current PRA ≥ 50% were excluded from ESW. Our initial protocol consisted of 4 doses of Thymoglobulin (ATG), 1.5 mg/kg, for induction, and mycophenolate mofetil (MMF) 1 g BID started day 1 + tacrolimus (TCL), started day 1-2 with target trough levels 10-12 ng/ml, for maintenance. After 1/20/04, pts with IGF were randomized to receive either TCL or sirolimus (SRL; troughs 10-12 ng/ml). Pt demographics were as follows: age 47 ± 13; 4.8 ± 3.9 years ESRD; 7% retransplant; 19% hepatitis C+; 19% live donor; 15 ± 7 hour cold ischemic time; 7% with current PRA ≥ 10%; 42% with peak PRA ≥ 10%; 4.4 ± 1.4 HLA mismatches; and 40% AA donor. Results: 48 pts were initiated on TCL, 9 on SRL. Conversions between maintenance agents were performed as clinically indicated for untoward side effects. Only 10 pts received > 4 (5-7) doses of ATG. Outcome data: delayed graft function (DGF): 39%; pt survival 98% at 1 yr, 95% overall; graft survival 96% at 1 yr, 89% overall; acute rejection (AR) 18%; CMV infection 7%; creatinine at 6 and 12 mo: 1.6 ± 0.5 and 1.7 ± 0.9 mg/dl, respectively; mean/median initial length of stay: 4.7/4 days. 6 graft losses were due to 3 deaths (2 malignancy, 1 infection), 1 noncompliance, and 2 FSGS. There were 2 cases of BK virus nephropathy. Of 10 pts developing AR, 2 were equivocal, 5 grade 1, 1 grade 2A, and 2 antibody-mediated. 46 pts (81%) remained steroid free at 1 yr, of which 11 (24%) were also calcineurin inhibitor free. % weight gain at 6 and 12 mo (3.6 ± 8.9 & 7.4 ± 8.9) and incidence of posttransplant diabetes (16%) in pts at risk were numerically less, but not significantly different from, values obtained in a group of 41 historical and concomitantly-treated AA RARs receiving ATG/MMF + TCL or SRL + maintenance steroids (4.4 ± 10.6 & 9.1 ± 14.5; 18%, respectively). Conclusions: Our findings suggest that ESW in AA RARs with multiple risk factors including DGF can produce excellent intermediate-term antirejection and graft functional outcomes. Our results will need to be verified in larger numbers of AA RARs with longer follow-up.
Published Version
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