Eva McKissick

Selective corticosteroid and calcineurin-inhibitor withdrawal after pancreas-kidney transplantation utilizing thymoglobulin induction and sirolimus maintenance therapy.

Abstract:  Of 25 simultaneous pancreas–kidney transplant (SPK) recipients treated with thymoglobulin induction, sirolimus and reduced‐dose cyclosporine (CsA), 18 low‐immune responders (non‐African–Americans, PRA < 30%) were withdrawn from prednisone on post‐transplant day 5, whereas seven high‐immune responders continued on prednisone. Most high‐ and low‐immune responder recipients were converted from CsA to mycophenolic acid (MPA) at six months post‐transplantation. At a mean follow‐up of 28 ± 10 months, two pancreas grafts were lost to pancreatitis. There were no patient or kidney graft losses, but one acute rejection episode. At 28 ± 11 months, all 18 low‐responder recipients remain steroid‐free. Twenty recipients (14 low and six high‐immune responders) were converted from CsA to MPA. During conversion, immune response was monitored by Flow‐PRA and T‐cell stimulation (Cylex) assays. Nineteen of 20 recipients displayed a post‐conversion PRA of 0%, whereas one highly sensitized patient expressed a post‐conversion PRA of 67%. Fifty‐eight percent of individual T‐cell stimulation scores were in the hypo‐responsive range. Twelve of 18 low‐immune responders are both steroid and CsA‐free at a mean follow‐up of 17 ± 13 months, whereas five of seven high‐immune responders remain CsA‐free at a mean follow‐up of 11 ± 10 months. These data suggest that thymoglobulin induction with combined sirolimus and CsA maintenance therapy permits immunosuppression minimization in selected SPK recipients.