Induction immunosuppressive therapy stratified according to risk categories in renal transplantation

Immunosuppressive therapy is critical during the induction phase for it directly affects graft outcome. Many centers use uniform regimens, although not all patients represent similar risks. The purpose of this study was to evaluate a prospective protocol of immunosuppression according to 2 significant risks in kidney transplant: acute rejection (AR) and delayed graft function (DGF).

This study included 35 patients (group I) stratified before starting the immunosuppression as follows: (1) standard risk, (2) increased risk of AR, and (3) augmented risk of DGF. Standard risk patients were treated with Cyclosporine (CsA) and Prednisone (Pred) (n = 18). Patients with increased risk of AR were treated with CsA plus Pred plus Mycophenolate Mofetil (n = 4) or sequential induction with antithymocyte globulin (n = 5). Patients with augmented risk of DGF were started on sequential induction with late inception of CsA (n = 8). Comparisons were made with a series of 20 patients (group II) who received a uniform regimen including CsA plus Pred plus Azathioprine.

AR and DGF rates were 6% and 16% for group I versus 39% and 39% for group II (P =.01 and P =.1, respectively). Serum creatinine values at 30 and 360 days were 1.43 +/- 0.45 and 1.29 +/- 0.40 in group I and 1.99 +/- 1.05 and 1.60 +/- 0.42 in group II (P <.05 for each comparison). Adverse effects, graft survival, and average costs were similar in both groups.

The use of differentiate protocols was associated with better graft function and a reduced frequency of AR and DGF. Although 50% of patients required sequential or triple-drug induction, the adverse events and costs were similar. These results encourage the use of individualized immunosuppression.