Improved outcome after 'bottom-up' immunosuppression in liver transplant recipients with preoperative renal impairment
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Published on: January 2, 2017
Andreas A Schnitzbauer1, Axel Doenecke, Johannes L Sothmann
1Kliniken und Polikliniken für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Germany. schnitzbauer @ klinik.uni-r.de
Background:
Most patients with high MELD scores have impaired renal function prior to transplantation.
Patient And Methods:
A retrospective case control study was conducted with initial low immunosuppression, which was increased when patients rejected or were clinically stable beyond day 30 ('bottom-up').
Results:
Thirty patients with impaired renal function were included. Fifteen were treated with de novo cyclosporine A (CsA; group A), and 15 had 'bottom-up' immunosuppression (group B). Baseline renal function was similar: serum creatinine (SCr) median 1.8 mg/dl (range: 1.5-4.0 mg/dl; group A) versus 2.4 mg/dl (range: 1.5-4.0 mg/dl; group B; p = 0.24). The requirement for renal replacement therapy was significantly lower in group B (p = 0.032). Ten received 'bottom-up' immunosuppression [4 CsA/1 sirolimus (Sir) 'on demand' after rejection, 5 Sir (stable)] beyond day 30. By months 6 and 12 (1.6 mg/dl vs. 1.2 mg/dl), SCr values were significantly better in group B (p = 0.006). Renal function in group B did not differ between patients receiving CsA or Sir. Overall complication rates, survival and biopsy-proven acute rejection were similar, although BANFF scores were higher in group B (p = 0.004).
Conclusion:
Successful implementation of 'bottom-up' immunosuppression in liver transplant recipients with high lab-MELD scores and renal dysfunction at the time of transplantation has the potential to substantially improve short- and long-term outcomes.
Insights
The "bottom-up" immunosuppression strategy in liver transplant patients with kidney dysfunction significantly reduced the need for renal replacement therapy and improved renal function compared to standard immunosuppression.
Area of Science:
- Nephrology
- Transplantation Medicine
- Immunology
Background:
- Patients with high Model for End-Stage Liver Disease (MELD) scores often present with impaired renal function before liver transplantation.
- Pre-existing renal dysfunction complicates post-transplant management and outcomes.
Purpose of the Study:
- To evaluate the efficacy of a 'bottom-up' immunosuppression protocol in liver transplant recipients with pre-existing renal dysfunction.
- To compare renal function and outcomes between 'bottom-up' and standard immunosuppression strategies.
Main Methods:
- A retrospective case-control study included 30 liver transplant recipients with impaired renal function.
- Group A (n=15) received de novo cyclosporine A (CsA).
- Group B (n=15) received 'bottom-up' immunosuppression, with initial low doses increased based on rejection or stability.
Main Results:
- Group B showed a significantly lower requirement for renal replacement therapy (p = 0.032).
- Serum creatinine levels were significantly better in Group B at 6 and 12 months post-transplant (p = 0.006).
- Overall complication rates, survival, and acute rejection were similar, though Banff scores were higher in Group B (p = 0.004).
Conclusions:
- The 'bottom-up' immunosuppression approach is feasible and beneficial for liver transplant recipients with renal dysfunction.
- This strategy may significantly improve both short- and long-term renal outcomes in this patient population.
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