CLINICAL IMMUNOSUPPRESSION - KIDNEY LATE

K. Lopau, A. Herzog, C. Wanner
Internal Medicine I, Division Of Nephrology, University of Wuerzburg, Wuerzburg/GERMANY

Body: Introduction: Steroid-free maintenance immunosuppression promises less metabolic complications in the long-run combined with the hazard of more immunological complications. Since 2000 we aimed for steroid-free IS in all patients under the premise of a therapy with CsA or Tacrolimus combined with mycophenolat (MPA). 315 patients were followed up until 12/31/2009. Methods: We compared the long-term outcome of 31 pts on Tac/MPA/Prednisolone (Pred)-maintenance with 38 pts on CsA/MPA/Pred, 114 with Tac/MPA and 132 on CsA/MPA. Steroids were tapered between month 9 and 15. We prospectively evaluated graft and patient survival, graft function, blood pressure (BP), incidences of metabolic and immunological complications. Mean observation time was 67 months. Results: Baseline parameters were comparable between groups despite original renal disease (more glomerulonephritis and less diabetic nephropathy in CsA/MPA/Pred), less mismatches in the CsA/MPA/Pred-group and less ATG-induction in both CsA-groups. DGF incidences were comparable with about 35% in all groups. Acute rejection episodes were significantly less frequent in the CsA+steroid group (7.9% vs CsA/MPA 20.4%, Tac/MPA/Pred 19.4%, Tac/MPA 14.1%). Between 0.6 an 2.2% of rejecting patients needed consecutive antibody-therapy. Biopsy-proven tubular atrophy / interstitial fibrosis (CAN) was demonstrated over time in 11.4% of all patients without significant differences between groups, we did not conduct protocol biopsies. Graft function (MDRD-GFR) was significantly better in the Tac/MPA-group at years 3 and 5 (mean differences 5.4 and 5.9 ml/min), but not thereafter. Systolic BP was significantly better in the Tac/MPA-group at year 1 and 3 (-5.3 and -2.3 mmHg). Diabetes incidences after transplantation (NODAT) amount to 19 to 28% and were comparable between groups. Neither typical steroid-related (osteoporosis, femoral neck necrosis, cataract etc) nor cardiovascular complications did depend on the therapy with steroids. We found significanty less cancer in patients receiving Tac/MPA compared to all other groups. Mean patient survival was 121 months, mean graft survival was 113 months without statistical differences. Conclusion: Our results provide further evidence for the safety and feasibility of steroid-free immunosuppression in the context of CNI-MPA-combinations. Despite an increased acute rejection rate (in both steroid-free groups), graft function was even better in the Tac/MPA-group. However, most likely due to low patient numbers still under observation after 5 years, this does not yet translate into lower CAN-rates or improved graft and patient survival.

Disclosure: All authors have declared no conflicts of interest.