title: Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis.
abstract: Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta-analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate- to high-strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard-dose regimens; moderate-strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate- to high-strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine-based strategies and low-risk populations. Additional research is needed with tacrolimus-based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient-centered outcomes.
authors.affiliation: Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: D
authors.initials: D
authors.lastname: Sawinski
authors.affiliation: Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.|Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: J
authors.initials: J
authors.lastname: Trofe-Clark
authors.affiliation: Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA.
authors.forename: B
authors.initials: B
authors.lastname: Leas
authors.affiliation: ECRI Institute, Plymouth Meeting, PA.
authors.forename: S
authors.initials: S
authors.lastname: Uhl
authors.affiliation: Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: S
authors.initials: S
authors.lastname: Tuteja
authors.affiliation: ECRI Institute, Plymouth Meeting, PA.
authors.forename: J L
authors.initials: JL
authors.lastname: Kaczmarek
authors.affiliation: Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: B
authors.initials: B
authors.lastname: French
authors.affiliation: Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.|Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA.|Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: C A
authors.initials: CA
authors.lastname: Umscheid
mesh_terms: D065095:Calcineurin Inhibitors / Q000627:therapeutic use*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery*; D007677:Kidney Function Tests; D016030:Kidney Transplantation; D011379:Prognosis; D015996:Survival Rate; D028761:Withholding Treatment
chemical_list: D065095:Calcineurin Inhibitors
keywords: calcineurin inhibitor (CNI); clinical research/practice; health services and outcomes research; immunosuppressant; immunosuppressive regimens; kidney transplantation/nephrology