Long-Term Results of Kidney Transplantation Between HLA-Identical Siblings

Surgery Today (Impact Factor: 0.96). 01/2001; 31(2):123-128. DOI: 10.1007/s005950170195

ABSTRACT Long-term data on HLA-identical renal transplants are scarce, and the advantages of using cyclosporine (CsA) over azathioprine
(AZA) have yet to be elucidated. In 68 recipients from HLA-identical donors (37 under AZA-steroids and 31 under CsA-steroids),
we estimated the graft and patient survival to posttransplant 120 months, and compared the results between patients on different
protocols. Episodes of rejection, causes of graft loss or patient death, and long-term complications were also compared retrospectively.
The 10-year patient/graft survivals were comparable: 82.7/67.6% for the AZA and 78.4/63.5% for the CsA patients. The incidence
of acute rejection during the first year after transplant was also comparable. We lost 25 grafts. The major causes of graft
loss were patient death (7/13 in AZA and 5/12 in CsA patients) and chronic rejection (3/13 in AZA and 3/12 in CsA patients).
Four grafts were lost due to poor compliance. We lost 12 patients due mostly to cerebrovascular disease and infections. There
was no difference in the prevalence of complications between patients. In conclusion, the long-term outcome was excellent
in this subgroup of transplant patients. We could not find any advantages of using CsA over AZA in these patients after a
long-term follow-up. To achieve better results, continued attention should be paid to the prevention of poor compliance and

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    ABSTRACT: Living-related (LR) human leukocyte antigen (HLA)-identical renal transplant (RTx) recipients often receive standard immunosuppression, despite the absence of mismatched major HLA-antigens and the known complications of long-term use of immunosuppression. No data are available on the need for immunosuppression for these specific patients. We wondered whether their immunosuppressive load could be radically reduced. Between November 1982 and November 2005, 83 LR HLA-identical RTx were performed in our center. Their unadjusted graft survival was 74% at 10 years. In 29 patients (median time after transplantation 5.6 [range 1.0-21.4] years) with stable uncompromised renal function, we tapered their immunosuppression from triple or dual therapy to prednisolone 5 mg/day. Follow up on prednisolone monotherapy was at least 24 months. In 27 of 29 patients reduction of immunosuppression to prednisolone monotherapy was uneventful. One patient, using dual therapy, developed JC-virus nephropathy resulting in graft loss. One refused further discontinuation of his medication. Four (15%) of the 27 patients on monotherapy developed biopsy-proven recurrence of their original disease. Only one of them showed a transient decline in renal function. One additional patient developed minor proteinuria and a rise in serum creatinine level, as a result of chronic urinary tract infections. The remaining 23 of 27 patients (85%) had an uneventful follow up during 24 months prednisolone monotherapy. We conclude that HLA-identical LR RTx recipients who are at least 1 year after transplantation might be treated with low-dose steroid monotherapy. Close surveillance of patients for recurrence of their original disease is recommended to allow for potential early therapeutic intervention.
    Transplantation 04/2009; 87(5):740-4. · 3.78 Impact Factor
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    ABSTRACT: Nonadherence to immunosuppressants is recognized to occur after renal transplantation, but the size of its impact on transplant survival is not known. A systematic literature search identified 325 studies (in 324 articles) published from 1980 to 2001 reporting the frequency and impact of nonadherence in adult renal transplant recipients. Thirty-six studies meeting the inclusion criteria for further review were grouped into cross-sectional and cohort studies and case series. Meta-analysis was used to estimate the size of the impact of nonadherence on graft failure. Only two studies measured adherence using electronic monitoring, which is currently thought to be the most accurate measure. Cross-sectional studies (n=15) tended to rely on self-report questionnaires, but these were poorly described; a median (interquartile range) of 22% (18%-26%) of recipients were nonadherent. Cohort studies (n=10) indicated that nonadherence contributes substantially to graft loss; a median (interquartile range) of 36% (14%-65%) of graft losses were associated with prior nonadherence. Meta-analysis of these studies showed that the odds of graft failure increased sevenfold (95% confidence interval, 4%-12%) in nonadherent subjects compared with adherent subjects. Standardized methods of assessing adherence in clinical populations need to be developed, and future studies should attempt to identify the level of adherence that increases the risk of graft failure. However, this review shows nonadherence to be common and to have a large impact on transplant survival. Therefore, significant improvements in graft survival could be expected from effective interventions to improve adherence.
    Transplantation 04/2004; 77(5):769-76. · 3.78 Impact Factor
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    ABSTRACT: Few prospective trials in human leukocyte antigen (HLA) identical living donor (LD) renal transplantation exist. This prospective study evaluated a corticosteroid (CS)-free, calcineurin inhibitor (CNI) minimization immunosuppressive regimen in HLA-identical LD renal transplant recipients. Twenty HLA-identical LD recipients were prospectively enrolled. Immunosuppression included mycophenolate mofetil (MMF) (2 g/day), tacrolimus (target trough 4-8 ng/mL), sirolimus (target trough 6-10 ng/mL), and no pre- or postoperative steroids. In the absence of prior rejection, tacrolimus was discontinued at posttransplant day 120 and sirolimus at 1 year, leaving patients on MMF monotherapy. Tacrolimus was successfully withdrawn in 94% of patients (16/17). One hundred percent (15/15) of patients who reached 1-year posttransplant had sirolimus discontinued. Ninety-four percent (17/18) of patients remain off CSs. Mean serum creatinine at 6, 12, and 24 months were 1.38+/-0.32, 1.35+/-0.37, and 1.25+/-0.29 mg/dL; corresponding mean calculated creatinine clearance estimates were 70+/-18, 73+/-17, and 72+/-15 mL/min. Acute cellular rejection, chronic allograft nephropathy, and CNI toxicity were not observed. Death-censored graft survival was 100% at last follow-up. A CS-free, CNI minimization immunosuppressive regimen with weaning to MMF monotherapy provides excellent renal function, graft survival, and patient survival in HLA-identical LD renal transplant recipients.
    Transplantation 03/2009; 87(3):408-14. · 3.78 Impact Factor