Kidney transplantation without calcineurin inhibitors using sirolimus.
BACKGROUND
With the introduction of new immunosuppressive medicines, it has become possible to determine the extent to which nephrotoxic medicines contribute to CAN. The aim of this study is to compare the safety and efficacy of calcineurin inhibitor (CI) free immunosuppression in a prospective, randomized trial comparing sirolimus-mycophenolate mofetil (MMF)-prednisone to tacrolimus- MMF-prednisone.


METHODS
Patients are randomized at the time of transplant to receive either tacrolimus (target level 12 to 15 ng/mL in the first month) or sirolimus (target level 12 to 18 ng/mL in the first month). All patients also receive MMF (750 mg bid) and prednisone tapered to 10 mg/d by 3 months and thymoglobulin induction (1.5 mg/kg/d on days 0, 1, 2, 4 and 6).


RESULTS
At this point we have 4-month follow-up in 85 patients. The acute rejection rate is 7.5% (3/40) in the tacrolimus group and 6.7% (3/45) in the sirolimus group. We have discontinued sirolimus in eight patients so far, with wound complications being the most common indication. Renal function appears to be better in the sirolimus group at 1 month after transplantation, but the difference is not statistically significant.


CONCLUSIONS
While longer follow-up is needed, these results demonstrate that total avoidance of CI can be achieved with extremely low acute cellular rejection rates using sirolimus-based immunosuppression in combination with thymoglobulin, MMF, and prednisone.
Department of Surgery, Mayo Foundation and Clinic, Rochester, Minnesota, USA. Stegall.mark@mayo.edu
M D
MD
Stegall
T S
TS
Larson
M
M
Prieto
J
J
Gloor
S
S
Textor
S
S
Nyberg
S
S
Sterioff
M
M
Ishitani
M
M
Griffin
W
W
Kremers
W
W
Lund
T
T
Schwab
F
F
Cosio
J
J
Velosa
D065095:Calcineurin Inhibitors; D004359:Drug Therapy, Combination; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006084:Graft Rejection / Q000276:immunology / Q000517:prevention & control; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D016030:Kidney Transplantation / Q000276:immunology* / Q000473:pathology / Q000502:physiology*; D016853:Muromonab-CD3 / Q000627:therapeutic use; D009173:Mycophenolic Acid / Q000031:analogs & derivatives* / Q000627:therapeutic use; D011241:Prednisone / Q000627:therapeutic use; D020123:Sirolimus / Q000627:therapeutic use*; D013997:Time Factors; D014184:Transplantation, Homologous / Q000473:pathology
D065095:Calcineurin Inhibitors; D007166:Immunosuppressive Agents; D016853:Muromonab-CD3; D009173:Mycophenolic Acid; D011241:Prednisone; D020123:Sirolimus