Prevention of CAN graft loss in the medium term without HLA disparity reduction

This study compares the incidence of cadaveric graft failure from chronic allograft nephropathy in the medium term (1 to 5 years) using older and newer immunosuppressive regimens. The older regimen was established triple therapy and the newer regimen, almost universal replacement of azathioprine by mycophenolate.

In the older series, 76 (71 after death censoring) cadaveric renal grafts done from 1990 to mid-1996 in patients who survived for more than 1 year were analyzed. In the newer series, 49 (45 after death censoring) cadaveric grafts done 5 or more years ago in patients surviving 1 year were analyzed. In the older series, immunosuppression was combined steroids, cyclosporine, and azathioprine. In the newer series, mycophenolate replaced azathioprine in 85%, historically conventional immunosuppression was used in 7.5%, and miscellaneous in 7.5%.

Cumulative deaths in years 1 to 5 with renal graft function were as follows: older series, 6.6% (5/76), newer 8.2% (4/49) (P = NS). In the older series, death-censored 1- to 5-year cumulative graft failure was 35.2% (24/71), newer series 4.4% (2/45) (chi-square 13.5, relative risk reduction 0.87 [0.51 to 0.97], P =.00021). ACE-inhibitor antihypertensive therapy was used in 25% (18/71) of the patients in the older series and in 53% (24/45) of patients in the newer series (chi-square 6.1, relative risk 1.8 [1.1 to 2.9], P =.01).

Replacement of azathioprine with mainly myocophenolate in triple immunosuppression and enhanced use of ACE inhibitors are associated with near complete prevention (87%) of medium-term CAN graft failure, making death with graft function now the major cause of graft loss in this time.