title: Preferential allocation of marginal kidney allografts to elderly recipients combined with modified immunosuppression gives good results.
abstract: BACKGROUND
  There is an increasing tendency to allocate kidneys from marginal donors in older recipients. This combination optimizes the uses of an expanded donor pool but demands attention for the higher nephrotoxic sensitivity of the kidney and the increased immunosuppression vulnerability of the elderly recipients. We aimed to reduce these hazards by means of a calcineurin-free induction therapy followed by a maintenance regimen targeted to minimize/withdraw steroid.
  
  
  METHODS
  Eighty-eight single (43%) or double (57%) transplant recipients (58.4+/-5.7 years) from 88 marginal donors (67+/-8.3 years) received monoclonal anti-IL-2 receptor antibodies, mycophenolate mofetil (MMF), and steroid. When serum creatinine was less than 2.6 mg/dL, tacrolimus was started and MMF was withdrawn when the tacrolimus trough level was above 15 ng/ml. Steroid was tapered to 5 mg at day 45 and then progressively reduced.
  
  
  RESULTS
  Overall patient and graft survival at the first and fourth year were respectively 100 and 96%, and 98 and 79%. Acute rejection rate was 13.6% (12/88), creatinine clearance remained stable (48.2 ml/min at the sixth month, 50.9 ml/min at 48th month). At the first, second, third, and fourth years, 23, 69, 80, and 100% of recipients were off steroids. For those on steroids, mean dose was respectively 2.6 mg/day from month 12. No recipient re-assumed steroids
  
  
  CONCLUSIONS
  In the "old-for-old" allocation, the calcineurin-inhibitor avoidance at induction and the steroid withdrawal/minimization during the tacrolimus-based maintenance regimen allow a low acute rejection rate, a stable renal function, and favorable recipient and graft outcomes.
authors.affiliation: Renal Transplant Unit, Nephrology, Dialysis and Transplantation Department, S.Giovanni Battista Hospital, Turin, Italy. giuseppe.segoloni@unito.it
authors.forename: Giuseppe P
authors.initials: GP
authors.lastname: Segoloni
authors.forename: Maria
authors.initials: M
authors.lastname: Messina
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Squiccimarro
authors.forename: Gianna
authors.initials: G
authors.lastname: Mazzucco
authors.forename: Elisa
authors.initials: E
authors.lastname: Torta
authors.forename: Gianluca
authors.initials: G
authors.lastname: Leonardi
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Fop
authors.forename: Stefano
authors.initials: S
authors.lastname: Roggero
authors.forename: Federica
authors.initials: F
authors.lastname: Vigotti
authors.forename: Giorgina B
authors.initials: GB
authors.lastname: Piccoli
mesh_terms: D000368:Aged; D002102:Cadaver; D006084:Graft Rejection / Q000517:prevention & control*; D006085:Graft Survival; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007668:Kidney / Q000502:physiology; D016030:Kidney Transplantation / Q000401:mortality; D014019:Tissue Donors / Q000600:supply & distribution; D014184:Transplantation, Homologous