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Published on: April 12, 2021
Lowering maintenance immune suppression in elderly kidney transplant recipients; connecting the immunological and
Michiel G H Betjes1, Annelies De Weerd1
1Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands.
Abstract:
The management of long-term immune suppressive medication in kidney transplant recipients is a poorly explored field in the area of transplant medicine. In particular, older recipients are at an increased risk for side effects and have an exponentially increased risk of infection-related death. In contrast, an aged immune system decreases the risk of acute T-cell-mediated rejection in older recipients. Recent advances in alloimmunity research have shown a rapid and substantial decline in polyfunctional, high-risk CD4+ T cells post-transplantation. This lowers the direct alloreactivity responsible for T-cell-mediated rejection, also known as donor-specific hyporesponsiveness. Chronic antibody-mediated rejection (c-aABMR) is the most frequent cause of kidney graft loss in the long term. However, in older adults, c-aABMR as a cause of graft loss is outnumbered by death with a functioning graft. In addition, DSA development and a diagnosis of c-aABMR plateau ~10 years after transplantation, resulting in a very low risk for rejection thereafter. The intensity of immune suppression regimes could likely be reduced accordingly, but trials in this area are scarce. Tacrolimus monotherapy for 1 year after transplantation seems feasible in older kidney transplant recipients with standard immunological risk, showing the expected benefits of fewer infections and better vaccination responses.
Insights
Reducing immunosuppression in older kidney transplant recipients may lower infection risks. Tacrolimus monotherapy for one year shows promise, reducing infections and improving vaccine responses in this population.
Area of Science:
- Transplant Medicine
- Immunology
- Nephrology
Background:
- Long-term immunosuppression management in kidney transplant recipients is under-researched.
- Older recipients face higher infection risks and mortality but lower T-cell rejection risk.
- Aging immune systems may contribute to donor-specific hyporesponsiveness post-transplantation.
Purpose of the Study:
- To explore the feasibility and outcomes of reduced immunosuppression in older kidney transplant recipients.
- To assess the impact of tacrolimus monotherapy on infection rates and immune responses in this demographic.
Main Methods:
- Review of current literature on immunosuppression in kidney transplantation.
- Analysis of outcomes in older adults regarding rejection and infection-related death.
- Evaluation of tacrolimus monotherapy trials in older kidney transplant recipients.
Main Results:
- Older recipients have a higher risk of infection-related death than T-cell-mediated rejection.
- Chronic antibody-mediated rejection (c-aABMR) and donor-specific antibody (DSA) development risk decreases significantly after 10 years.
- Tacrolimus monotherapy for one year appears feasible, reducing infections and improving vaccination responses in older recipients with standard immunological risk.
Conclusions:
- Reduced immunosuppression intensity may be safe and beneficial for older kidney transplant recipients.
- Tacrolimus monotherapy is a potential strategy for long-term management in this population.
- Further trials are needed to confirm the optimal immunosuppression strategy for older kidney transplant recipients.
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