101. Minimizing ciclosporin in renal transplant recipients on daclizumab, mycophenolate and steroids.
- Author
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Bunnapradist, S. and Danovitch, G. M.
- Subjects
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IMMUNOSUPPRESSIVE agents , *KIDNEY transplantation , *NEPHROTOXICOLOGY , *GLOMERULAR filtration rate , *HEALTH outcome assessment - Abstract
BACKGROUND There is great interest in reducing exposure of renal transplant recipients to the nephrotoxic effects of calcineurin inhibitors. OBJECTIVE To establish whether minimization or withdrawal of ciclosporin improves outcome after renal transplantation in patients receiving daclizumab, mycophenolate mofetil and corticosteroids. DESIGN Recipients of a first renal transplant were prospectively recruited from sites in Australia, Europe and North America for the randomized, open-label Cyclosporine Avoidance Eliminates Serious Adverse Renal Toxicity (CAESAR) trial. Exclusion criteria included receipt of an HLA-identical living related graft, a panel-reactive antibody value >20% in the previous 6 months, and an expected need for antilymphocyte treatment for delayed graft function. INTERVENTION In addition to mycophenolate and corticosteroids, participants were randomly allocated (1:1:1) to receive standard-dose ciclosporin; daclizumab induction plus low-dose ciclosporin; or daclizumab induction plus a maximum of 6 months' treatment with low-dose ciclosporin. In the third group, ciclosporin withdrawal began at month 4. Target ciclosporin trough levels were 50-100 ng/ml for low-dose treatment and 150-300ng/ml for the first 4 months of standard-dose treatment (100-200 ng/ml subsequently). Follow-up continued for 12 months OUTCOME MEASURES Glomerular filtration rate (GFR) 12 months after transplantation, as determined by clearance of an exogenous substrate, was the primary end point. Secondary end points included biopsy-proven acute rejection, graft failure and patient mortality. RESULTS Between 12 January 2001 and 24 October 2002, the investigators recruited 536 patients. In the intention to treat analysis, mean GFR at 12 months after transplantation was 50.9 ml/min/1.73 m² in both the ciclosporin withdrawal group (n = 128) and low-dose ciclosporin group (n = 138); mean GFR was 48.6ml/min/1.73m² in the standard- dose ciclosporin group (n = 119). There was no significant difference between these values. In addition, GFR at 3 months after transplantation, and creatinine clearance at 12 months after transplantation (calculated using the Cockcroft-Gault equation), did not differ significantly between the groups. Compared with the low-dose and standard-dose ciclosporin groups, a higher proportion of patients in the ciclosporin withdrawal group experienced a first episode of biopsy-proven acute rejection during the 12 months of follow-up (38% vs 25.4% and 27.5%; P=0.027 and P=0.040, respectively). There were 12 graft losses in the ciclosporin withdrawal group, 6 in the low-dose ciclosporin group and 9 in the standard-dose ciclosporin group (P= NS); 8, 4 and 5 patients died, respectively. The incidences of serious and ciclosporin-related adverse events did not differ significantly between the three groups. CONCLUSION In renal transplant patients receiving daclizumab, mycophenolate and corticosteroids, low-dose ciclosporin (target trough levels 50-100 ng/ml) produces 1-year outcomes similar to those obtained with standard-dose ciclosporin. [ABSTRACT FROM AUTHOR]
- Published
- 2007
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