Low dose Triple Immunosuppression in Live Renal Transplantation is enough to prevent Acute Rejection

Low dose Triple Immunosuppression in Live Renal Transplantation is enough to prevent Acute Rejection

44 Indian Journal of Transplantation was good. All these findings ruled out possibility of renal graft rejection. Normal Tacrolimus serum level(7. 5...

45KB Sizes 1 Downloads 72 Views

44

Indian Journal of Transplantation

was good. All these findings ruled out possibility of renal graft rejection. Normal Tacrolimus serum level(7. 5 ng/ ml) ruled out CNI toxicity. At this stage Bk virus nephropathy was suspected. Renal biopsy was done, which showed interstitial nephritis with intranuclear inclusions suggestive of polyoma virus infection. Urine sample cytology revealed few uroepithelial cells showing intracellular inclusions(decoy cells) suggesting polyoma infection. So diagnosis of polyoma virus(BKV) was confirmed and patient was treated by reducing the immunosuppressive drug dosage. Tac. 4mg per day, MMF 250mg BD, prednisolone 5mg were the reduced dosage administered. Also Tab. Leflunomide(ARAVA) 100 mg once a day for 6 days followed by 20 mg OD for 3 months was given. Patient showed remarkable improvement. Renal function improved. On 13th Jan 2007 her blood urea 38mg/dl sr. creatinine 1. 3mg/dl.

Live Renal Transplant Patients on Low Dose Triple Immunosuppression – 2 year follow-up Data C Arvind, Sanjeev Hiremath K. R. and D. G. Hospitals, Bangalore

We present here the follow –up data of our live renal transplant patients on low-dose triple immunosuppression, Cyclosporine (Cya), Mycofenolate Mofetil (MMF) or Azathioprine and Prednisolone, at the end of two years. Of the 41 patients who underwent a transplant between the years 2003 to 2007, 22 patients completed 2 years of follow-up. Data was collected from these patients retrospectively at the end of 1 and 2 yrs. The male to female ratio was 9:2 and the average age of the patients 49. 3yrs. Of these 22 pts, one pt died of IHD with a functioning graft (SCr 0. 9mg/dl), another developed chronic graft dysfunction after stopping medications and lost her graft function at 16 months after transplant. The remaining 20 pts carried on with good graft function. Of these 20, there were 3 pts with recurrent UTI, 4 pts with herpes zoster and one with miliary TB. 3 pts had persistent lymphcoele that required surgery. The mean serum creatinine level was 1. 23mg/dl at the end of 1 year and 1. 51mg/dl at the end of 2 years. The mean Cya dose was 2. 86mg/kg/day at the end of 1yr and 2. 18mg/kg/ day at the end of 2 years. The mean MMF dose was 1. 1gm/day at the end of one year and 0. 82gm/day at the end of 2 years. Azathioprine was continued in 3 pts at 100mg/day. One patient was off steroid and the others were on 5-10mg/ day of prednisolone at the end of 2 years.

Conclusion : Good graft function was maintained despite the use of Copyright © 2008 by The Indian Society of Organ Transplantation

Indian J Transplant 2008; 2: 32-50

low-dose triple immunosuppression. UTI and Zoster accounted for the majority of infections in this group while surprisingly, CMV infections did not occur despite the use of MMF. The dosages of Cya and MMF after the early post-transplant period have not been established, but it appears that lower doses of these medicines are still as effective.

Low dose Triple Immunosuppression in Live Renal Transplantation is enough to prevent Acute Rejection C Arvind, Sanjeev Kumar Hiremath KR and DG Hospitals, Bangalore

Conventionally and according to studies from the west, Cyclosporine is started at 8mg/kg/day in renal transplant patients with set trough and 2-hr goals to achieve. Mycofenolate Mofetil (MMF) is usually used at 2 to 3gm per day together with steroids as the triple immunosuppression regimen in live renal transplant recipients. Recently Tacrolimus has been preferred over Cyclosporine. Induction therapy has also gained ground. We conducted a retrospective analysis of transplant patients who underwent live renal transplant surgery between May 2003 and May 2007 in our transplant units. There were 41 patients with a mean age of 48. 32years (range 15 – 59years), male to female ratio of 29:12. Mean cyclosporine (Cya) dose at day 7 was 5. 92mg/kg/day. 33 patients were given 1gm/day of MMF , 2 patients received 1. 5gm of MMF and 1 patient received 2gm/ day; 4 patients received Azathioprine at 100mg/day. Methylprednisolone 500mg IV was given at the time of anastomosis followed by IV hydrocortisone 100mg 6hrly for 2days, then switched to oral prednisolone at 1mg/kg/ day tapered by 5mg per day to 30mg/day at discharge. No induction therapy was used. Mean serum creatinine level at discharge was 1. 38mg/dl. Mean 2hr Cya level done on day 6 for 38 of the 41 pts was 679ng/ml. Delayed graft function (DGF) was noted in 9 patients and transplant biopsy was done in these patients. 8 patients had ATN. 1 had acute rejection (AR) that responded to methylprednisolone IV pulse.

Conclusion : Low dose Triple Immunosuppression in Live Renal Transplantation is enough to prevent acute rejection early in the post-transplant period. ATN is the more common cause of DGF in our series. The 2 Hr Cya levels necessary to prevent AR in our population is probably much lower than western standards but will need RCTs to confirm.