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Pediatric renal transplants--results with sequential immunosuppression
P S Almond1, A J Matas, K Gillingham
1Department of Surgery, University of Minnesota, Minneapolis 55455.
Insights
Sequential immunosuppression with Cyclosporine (CsA) significantly improved pediatric renal transplant outcomes, enhancing patient and graft survival rates. This approach led to better graft survival and fewer rejections compared to older methods.
Area of Science:
- Nephrology
- Immunosuppression Therapy
- Pediatric Transplantation
Background:
- Cyclosporine (CsA) has revolutionized renal transplantation outcomes.
- Sequential immunosuppression protocols, including CsA, were implemented in pediatric renal transplant recipients starting in 1984.
Purpose of the Study:
- To evaluate the outcomes of pediatric renal transplants using a sequential immunosuppression protocol involving Cyclosporine (CsA).
- To compare these outcomes with historical data from transplants performed without CsA.
Main Methods:
- A retrospective study of 131 pediatric renal transplants (age ≤ 18) performed between June 1984 and March 1991 using sequential immunosuppression (MALG, AZA, P, delayed CsA).
- Comparison with 144 pediatric renal transplants performed since January 1980 without CsA.
- Analysis of graft survival, patient survival, hospital readmissions, rejection episodes, and serum creatinine levels.
Main Results:
- The sequential immunosuppression group showed a 1-year actuarial graft survival of 93% and 100% patient survival.
- Compared to the non-CsA group (82% graft survival, 94% patient survival), sequential immunosuppression significantly improved patient (P = 0.003) and graft survival (P = 0.004).
- No significant differences were observed in readmissions, rejection episodes, or serum creatinine levels between the two groups.
Conclusions:
- Sequential immunosuppression with Cyclosporine (CsA) significantly enhances patient and graft survival in pediatric renal transplantation.
- While CsA improved survival rates, it did not significantly alter readmission rates, rejection episodes, or renal function compared to non-CsA protocols.
- Living donor recipients experienced fewer rejection episodes than cadaveric recipients in the CsA group.
Abstract:
Cyclosporine has improved the results of renal transplantation. In 1984, we began using it as part of a sequential immunosuppression protocol (MALG, AZA, P, and delayed administration of CsA) in our pediatric renal transplant recipients. We studied the outcome of the 131 pediatric renal transplants (less than or equal to 18 years of age at transplant) performed at our institution between June 1984 and March 1991. We compared these results with the 144 similar transplants performed since January 1980 that did not involve CsA immunosuppression. In the sequential immunosuppression group, there were 97 primary (74%) (26 [27%] cadaver, 71 [73%] living donor [LD]) and 34 (26%) retransplant (23 [68%] CAD, 11 [32%]) recipients. Age at transplant (mean +/- SD) was 7.4 +/- 5.5. Overall, 1-year actuarial graft survival was 93%; 1-year patient survival was 100%. The mean number of hospital readmissions was 3.0 +/- 3.5; 26 (20%) were readmission-free. The mean number of rejection episodes was .87 +/- 1.3 per patient; 73 (56%) were rejection-free. Importantly, LD (vs. CAD) recipients had fewer rejection episodes (P = 0.06). In the first post-transplant year, the serum creatinine level was significantly lower in primary (vs. retransplant) recipients and in LD (vs. CAD) recipients (P less than 0.05). In the 144 patients not receiving CsA, there were 129 (90%) primary (27 CAD, 102 LD) and 15 (10%) retransplant (7 CAD, 8 LD) recipients. Age at transplant was 6.9 +/- 5.3 years. The 1-year actuarial graft survival rate was 82%; the 1-year patient survival rate was 94%. The mean number of hospital readmissions was 3.3 +/- 2.3; 5 (8%) were readmission-free. The mean number of rejection episodes was 1.2 +/- 1.5; 27 (45%) were rejection-free. There was no difference in the serum creatinine level based on donor source or transplant number. Sequential immunosuppression has significantly improved patient (P = 0.003) and graft survival (P = 0.004) rates. Comparing sequential vs. non-CsA immunosuppression, there was no difference in the number of readmissions (P = 0.47), number of rejection episodes (P = 0.17), or serum creatinine level. The number of rejection-free patients was significantly lower in LD (vs. CAD) recipients (P less than 0.05). There was no evidence of progressive deterioration in renal function in the sequential (vs. non-CsA) recipients.