TWO IMMUNOSUPPRESSIVE PROTOCOLS FOR RENAL PATIENTS TRANSPLANTED FROM MARGINAL DONORS ACCORDING TO AN “OLD FOR OLD” ALLOCATION.

Abstract

P729 Aims: When transplanting kidneys from marginal donors (MDs) with an “old for old” allocation, immunosuppression should be tailored either on the recipient or on the donor‘s characteristics, because elderly recipients are more fragile and marginal kidneys are more susceptible to nephrotoxic injuries. A calcineurin-inhibitors (CIN) free strategy during the induction phase may be a good solution but one cannot deny the existence of a greater risk for acute rejection. As for the maintenance phase tacrolimus (TAC) increases the diabetes occurence in comparison with Cyclosporine A (CyA), but the latter, in spite of the association with mycophenolate mofetil (MMF) seems to increase the acute rejection rate, particularly when tapering steroids. Aim of the study: on the basis of these informations (from literature and from personal experience) we decided to compare the short-term effects (6 months) of the two drugs used in 135 recipients of single/dual grafts from MDs with a protocol CIN free in the induction phase (basiliximab+steroids+MMF). Methods: MDs all ≥ 50 years old, renal biopsy before grafting, TAC (n=90 patients) or CyA (n=45 patients) added when serum Creatinine (sCr) ≤ 2.5 mg/dl. TAC and CyA groups were homogeneus for all parameters (donors gender and age, recipients gender) with the exception of cold ischemia time (longer in CyA group) and recipient’s age (older in TAC group). The groups were compared as for survival (Kaplan Meier estimates log rank for significance) and adverse events. Results: TAC and CyA patients behaved similarly as for delayed graft function (DGF; TAC 47%, CyA 37%) and acute rejection rate (total: TAC 14%, CyA 20%; during the CIN–free phase: TAC 8%, CyA 11%), sCr (TAC 1.6 ± 0.6, CyA 1.6 ± 0.5 mg/dL), steroid dose (TAC 3.3 ± 1.4, CyA 5 ± 6 mg/day). De novo insulin therapy was mostly required in TAC group as it was expected (18.2% vs 4.7%). Diabetes rate after 6 months, again, was higher in TAC group but statistically significance versus CyA group was not reached (11.4% vs 2.4% p=NS), perhaps because of small numbers. No statistically significant difference as for graft and patient survival was noted, in spite of the fact that TAC patients exihibit better results. Conclusions: When adopting a CIN free protocol for grafts from MDs with an “old for old” allocation, acute rejection rate is low in the induction phase and also afterwards, when either TAC or CyA are added. Graft and patient survivals are good with both drugs. TAC is associated with a statistically greater number of post transplantation diabetes but it allows an easier and safer tapering of steroids. Also by means of the steroid dose reduction, insulin is no more required in 50% of the patients at 6 months. In a CyA regimen, diabetes rate is very low and acute rejection rate is slightly, but not significatly, increased.