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Pérez-Sáez MJ, Montero N, Oliveras L, Redondo-Pachón D, Martínez-Simón D, Abramovicz D, Maggiore U, Mariat C, Mjoen G, Oniscu GC, Peruzzi L, Sever MS, Watschinger B, Velioglu A, Demir E, Gandolfini I, Hellemans R, Hilbrands L, Pascual J, Crespo M. Immunosuppression of HLA identical living-donor kidney transplant recipients: A systematic review. Transplant Rev (Orlando) 2023; 37:100787. [PMID: 37657355 DOI: 10.1016/j.trre.2023.100787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/29/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Kidney transplant (KT) recipients of HLA identical siblings (HLAid) have lower immunological risk, but there are no specific recommendations for immunosuppression. Our aim was to analyze evidence about results from HLAid living-donor recipients under different immunosuppression in the current era of immunological risk assessment. METHODS Systematic review of studies describing associations between outcomes of HLAid living-donor KT recipients according to their immunological risk and applied immunosuppression. RESULTS From 1351 studies, 16 (5636 KT recipients) were included in the analysis. All studies were retrospective, ten comparing immunosuppression strategies, and six immunological risk strata. Of those ten, six studies were published in 1990 or earlier and only three included tacrolimus. The evidence is poor, and the inclusion of calcineurin inhibitors does not demonstrate better results. Furthermore, only few studies describe different immunosuppression regimens according to the patient immunological risk and, in general, they do not include the assessment with new solid phase assays. CONCLUSIONS There are no studies analyzing the association of outcomes of HLAid KT recipients with current immunological risk tools. In the absence of evidence, no decision or proposal of immunosuppression adapted to modern immunological risk assessment can be made currently by the Descartes Working Group.
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Affiliation(s)
| | - Núria Montero
- Nephrology Department, Hospital de Bellvitge, Barcelona, Spain
| | - Laia Oliveras
- Nephrology Department, Hospital de Bellvitge, Barcelona, Spain
| | | | | | - Daniel Abramovicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Christophe Mariat
- Nephrology Dialysis and Renal Transplantation Dpt, CHU de Saint-Etienne, Université Jean Monnet, Saint-Etienne, France
| | - Geir Mjoen
- Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Turin, Italy
| | - Mehmet Sükrü Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Arzu Velioglu
- Marmara University, School of Medicine, Department of Nephrology, Istanbul, Turkey
| | - Erol Demir
- Transplant Immunology Research Centre of Excellence, Koç University Hospital, Istanbul, Turkey
| | - Ilaria Gandolfini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rachel Hellemans
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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Bentata Y, ElKabbaj D, Bahadi A, Rhou H, Laouad I, Sqalli T, Bouattar T, Ouzeddoun N, Bayahia R, Ramdani B. HLA‐identical living related kidney transplantation: Outcomes of a national multicenter study. Int J Urol 2022; 29:519-524. [DOI: 10.1111/iju.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/18/2022] [Accepted: 02/02/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Yassamine Bentata
- Department of Nephrology—Dialysis and Kidney Transplantation University Hospital Mohammed VI University Mohammed First OujdaMorocco
- Laboratory of Epidemiology Clinical Research and Public Health Medical School University Mohammed First OujdaMorocco
| | - Driss ElKabbaj
- Department of Nephrology—Dialysis and Kidney Transplantation Military University Hospital Mohammed V University Mohammed V RabatMorocco
| | - Abdelaali Bahadi
- Department of Nephrology—Dialysis and Kidney Transplantation Military University Hospital Mohammed V University Mohammed V RabatMorocco
| | - Hakima Rhou
- Department of Nephrology—Dialysis and Kidney Transplantation University Hospital Cheikh Zaid University Abulcasis RabatMorocco
| | - Inass Laouad
- Department of Nephrology—Dialysis and Kidney Transplantation University Hospital Mohammed VI University Cadi Ayyad MarrakechMorocco
| | - Tarik Sqalli
- Department of Nephrology—Dialysis and Kidney Transplantation University Hospital Hassan II University Sidi Mohammed Benabdellah FesMorocco
| | - Tarik Bouattar
- Department of Nephrology—Dialysis and Kidney Transplantation University Hospital Ibn Sina University Mohammed V RabatMorocco
| | - Naima Ouzeddoun
- Department of Nephrology—Dialysis and Kidney Transplantation University Hospital Ibn Sina University Mohammed V RabatMorocco
| | - Rabia Bayahia
- Department of Nephrology—Dialysis and Kidney Transplantation University Hospital Ibn Sina University Mohammed V RabatMorocco
| | - Benyouns Ramdani
- Department of Nephrology—Dialysis and Kidney Transplantation Unit University Hospital Ibn Rochd University Hassan II Casablanca Morocco
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Mycophenolate Monotherapy in HLA-Matched Kidney Transplant Recipients: A Case Series of 20 Patients. Transplant Direct 2020; 6:e526. [PMID: 32095512 PMCID: PMC7004628 DOI: 10.1097/txd.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/04/2019] [Accepted: 10/26/2019] [Indexed: 11/26/2022] Open
Abstract
The ideal minimizing strategy for maintenance immunosuppression in HLA-matched kidney transplant recipients (KTR) is unknown. We hypothesized that mycophenolate (MPA) monotherapy is a safe and effective approach for maintenance therapy in this group of KTR. Methods Data were abstracted for 6-antigen HLA-matched KTR between 1994 and 2013. Twenty recipients receiving MPA monotherapy secondary to infection, cancer, calcineurin inhibitor (CNI) side effects, or immunosuppression minimization strategies were evaluated in this case series. Results MPA monotherapy had a low incidence of death-censored graft failure (3.19/100 person-y), rejection (0/100 person-y), hospitalization (1.62/100 person-y), malignancy (3.61/100 person-y), and infection (1.75/100 person-y). Further, 12-month mean or median serum creatinine (1.29 mg/dL), estimated glomerular filtration rate (64.3 mL/min/1.73 m2), urine protein creatinine ratio (143.2 mg/g), hemoglobin (13.9 g/dL), platelets (237.8 K/uL), and white blood cell count (9.04 K/uL) were favorable. There was a successful conversion rate of 90% (18 of 20) with 2 patients converting back to CNI-based regimens secondary to recurrence of membranous nephropathy and post-transplant lymphoproliferative disorder. Conclusions Our findings indicate that MPA monotherapy may be a promising immunosuppression minimization strategy for HLA-matched KTR.
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Immunosuppression and Graft Rejection in Living-related HLA-identical Renal Transplantation: The RADOVFULL Study. Transplantation 2019; 104:1256-1262. [PMID: 31465001 DOI: 10.1097/tp.0000000000002937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We aimed to describe the immunosuppressive regimens and graft rejection rates in living-related HLA-identical (LR HLAid) renal transplantation. METHODS We performed a retrospective multicenter analysis of the French national database for LR HLAid renal transplantations performed between 2002 and 2012. Univariate and multivariate analysis were performed to determine risk factors for graft rejection in LR HLAid recipients. RESULTS A total of 27 218 renal transplantations were performed, of whom 163 had a LR HLAid donor. About immunosuppressive treatment, <60% of the cohort had induction therapy with polyclonal or monoclonal antibodies, 28% did not receive calcineurin inhibitors, and 36% did not receive steroids in maintenance. Biopsy-proven acute rejection was diagnosed in 21 patients (12.9%). Rejection occurred on an average of 24 months after transplantation, in 28.5% of the cases after minimization of immunosuppression. Factors associated with rejection were age of recipient (OR, 0.91 [0.84-0.96]; P = 0.003), the body mass index of donors (odds ratio [OR], 1.22 [1.04-1.46]; P = 0.01), and minimization of immunosuppression (OR, 26.2 [5.48-166.6]; P < 0.001). Overall and graft survival rates were not statistically different according to rejection at 1, 5, and 10 years posttransplantation. CONCLUSIONS Minimization of immunosuppression should be done with caution in LR HLAid renal transplantations.
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Boran M, Boran M, Boran E. HLA-identical sibling renal transplantation: influence of donor and recipient gender mismatch on long-term outcomes. Transplant Proc 2014; 46:3423-5. [PMID: 25498065 DOI: 10.1016/j.transproceed.2014.06.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/14/2014] [Accepted: 06/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Long-term function of living-related kidney allograft depends on multiple variables. The aim of the present study was to assess the influence of donor and recipient gender mismatch on the short and long-term outcomes in human leukocyte antigen (HLA)-identical sibling renal transplants (SRTs) receiving induction therapy and different immunosuppressive regimens. MATERIAL AND METHODS Twenty-nine recipients who were grafted from their HLA-identical siblings between 1994 and 2008 were divided into 2 groups (same and mismatched) according to gender of donor and recipient. The analyzed variables were age, gender, cholesterol, triglyceride, proteinuria, estimated glomerular filtration rate, weight, body mass index, and serum creatinine at 6, 12, 24, 36, 48, and 60 months, and median follow-up. Univariate and multivariate logistic regression models (when appropriate) were used to evaluate the effects of variables on allograft survival. RESULTS The number of male donors (P = .001) and recipient age (P = .019) was significantly higher in the same gender group than in mismatched gender group; there were no relationships between remainder analyzed parameters. Multivariate regression analysis revealed that after median follow-up period of 84 months (range, 60-232) the most important potential factors to significantly influence long-term outcomes were male donor (P = .002), recipient age (P < .001), and donor age (P = .021). CONCLUSION Our study demonstrated that male donor, and donor and recipient age affected long-term survival of HLA-identical SRTs, supported with antibody induction therapy and lifetime immunosuppression.
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Affiliation(s)
- Mediha Boran
- Department of Nephrology, Hemodialysis and Transplantation, Turkiye Higher Education Hospital, Ankara, Turkey.
| | - Mertay Boran
- Department of Thoracic Surgery, Duzce University School of Medicine, Duzce, Turkey
| | - Ertay Boran
- Department of Anesthesiology and Reanimation, Duzce University School of Medicine, Duzce, Turkey
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Verghese PS, Dunn TB, Chinnakotla S, Gillingham KJ, Matas AJ, Mauer MS. Calcineurin inhibitors in HLA-identical living related donor kidney transplantation. Nephrol Dial Transplant 2014; 29:209-18. [PMID: 24414376 DOI: 10.1093/ndt/gft447] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Given the nephrotoxicity of calcineurin inhibitors (CNIs), we asked whether their addition improved living related donor (LRD) human leukocyte antigen (HLA) identical kidney transplant recipient outcomes. METHODS We performed a comprehensive literature review and a single-center study comparing patient survival (PS) and graft survival (GS) of LRD HLA-identical kidney transplants for three different immunosuppression eras: Era 1 (up to 1984): anti-lymphocyte globulin (ALG) induction and maintenance immunosuppression with prednisone and azathioprine (AZA) (n = 114); Era 2a (1984-99): CNI added; evolution from ALG to thymoglobulin; AZA to mycophenolate (n = 262). Era 2b (1999-2011): rapid discontinuation of prednisone (thymoglobulin induction, CNI and mycophenolate) in recipients having first or second transplant and not previously on prednisone (n = 77). RESULTS Demographics differed by era: recipient (P < 0.0001) and donor age (P < 0.0001) increased and the proportion of Caucasian donors (P = 0.02) and recipients (P = 0.003) decreased with each advancing era. There was no significant difference in PS (P = 0.6); cause of death (P = 0.5); death-censored GS (P = 0.8) or graft loss from acute rejection by era. Graft loss from chronic allograft nephropathy (P = 0.02) and hypertension (P = 0.005) were greater in the CNI eras. There were no significant differences in the 1/creatinine slopes between eras for the first (P = 0.6), second (P = 0.9) or >2 years post-transplant (P = 0.4). Literature review revealed no clear benefits for CNI in these human leukocyte antigen (HLA) identical LRD graft recipients. CONCLUSIONS This study confirmed that there are no benefits of CNIs for HLA-identical LRD recipients. Moreover, we did find evidence of potential harm. Thus, monotherapy or early discontinuation of CNI should be given consideration in these patients.
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Affiliation(s)
- Priya S Verghese
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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Gascó B, Revuelta I, Sánchez-Escuredo A, Blasco M, Cofán F, Esforzado N, Quintana LF, Ricart MJ, Torregrosa JV, Campistol JM, Oppenheimer F, Diekmann F. Long-term mycophenolate monotherapy in human leukocyte antigen (HLA)-identical living-donor kidney transplantation. Transplant Res 2014; 3:4. [PMID: 24491040 PMCID: PMC3943084 DOI: 10.1186/2047-1440-3-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/07/2014] [Indexed: 02/02/2023] Open
Abstract
UNLABELLED Although recipients of a first HLA-identical living-donor kidney transplant seem to need less immunosuppression, there are no guideline recommendations for these patients, and few prospective trials are available. METHODS We analyzed all PRA-negative patients who received a first kidney transplant from an HLA-identical living donor. The patients received no antibody induction. An intraoperative bolus of 500 mg of methylprednisolone was administered. Then, steroid therapy was withdrawn within one week. Tacrolimus and mycophenolate treatment were started 3 days before transplantation with tacrolimus target levels of 4 to 8 ng/mL. In the absence of rejection, tacrolimus was withdrawn between 3 and 12 months post-transplant to reach mycophenolate mofetil monotherapy of 2 g/day or equivalent. RESULTS Six patients were treated with the above protocol. At last follow-up, graft and patient survival were 100%. MDRD glomerular filtration rates were 54, 60, and 62 mL/min at 3 months, 12 months and last follow-up, respectively. None of the patients developed PRA post-transplant. One episode of acute rejection Banff IA occurred 9 years after transplantation due to non-adherence with good outcome after treatment. The mean number of concomitant drugs given with mycophenolate was 2.6. Four patients needed antihypertensive drugs. CONCLUSION Steroid-free de novo treatment and calcineurin-inhibitor weaning with mycophenolate monotherapy is feasible in first HLA-identical kidney transplantation from a living sibling.
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Affiliation(s)
- Blanca Gascó
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
- Servicio de Nefrología, Hospital Universitario Virgen Macarena, Avd. Dr. Fedriani, 3, 41007 Sevilla, Spain
| | - Ignacio Revuelta
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Ana Sánchez-Escuredo
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Miquel Blasco
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Federico Cofán
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Nuria Esforzado
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Luis F Quintana
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - María José Ricart
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - José Vicente Torregrosa
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Josep M Campistol
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Federico Oppenheimer
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
| | - Fritz Diekmann
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Villarroel 170 08036 Barcelona, Spain
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Calcineurin Inhibitor–Free Monotherapy in Human Leukocyte Antigen–Identical Live Donor Renal Transplantation. Transplantation 2011; 91:330-3. [PMID: 21344733 DOI: 10.1097/tp.0b013e3182033ef0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van de Wetering J, Gerrits JH, van Besouw NM, Ijzermans JNM, Weimar W. Successful tapering of immunosuppression to low-dose monotherapy steroids after living-related human leukocyte antigen-identical renal transplantation. Transplantation 2009; 87:740-4. [PMID: 19295320 DOI: 10.1097/tp.0b013e31819634eb] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Living-related (LR) human leukocyte antigen (HLA)-identical renal transplant (RTx) recipients often receive standard immunosuppression, despite the absence of mismatched major HLA-antigens and the known complications of long-term use of immunosuppression. No data are available on the need for immunosuppression for these specific patients. We wondered whether their immunosuppressive load could be radically reduced. METHOD Between November 1982 and November 2005, 83 LR HLA-identical RTx were performed in our center. Their unadjusted graft survival was 74% at 10 years. In 29 patients (median time after transplantation 5.6 [range 1.0-21.4] years) with stable uncompromised renal function, we tapered their immunosuppression from triple or dual therapy to prednisolone 5 mg/day. Follow up on prednisolone monotherapy was at least 24 months. RESULTS In 27 of 29 patients reduction of immunosuppression to prednisolone monotherapy was uneventful. One patient, using dual therapy, developed JC-virus nephropathy resulting in graft loss. One refused further discontinuation of his medication. Four (15%) of the 27 patients on monotherapy developed biopsy-proven recurrence of their original disease. Only one of them showed a transient decline in renal function. One additional patient developed minor proteinuria and a rise in serum creatinine level, as a result of chronic urinary tract infections. The remaining 23 of 27 patients (85%) had an uneventful follow up during 24 months prednisolone monotherapy. CONCLUSION We conclude that HLA-identical LR RTx recipients who are at least 1 year after transplantation might be treated with low-dose steroid monotherapy. Close surveillance of patients for recurrence of their original disease is recommended to allow for potential early therapeutic intervention.
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Affiliation(s)
- Jacqueline van de Wetering
- Department of Internal Medicine and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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A prospective trial of a steroid-free/calcineurin inhibitor minimization regimen in human leukocyte antigen (HLA)-identical live donor renal transplantation. Transplantation 2009; 87:408-14. [PMID: 19202447 DOI: 10.1097/tp.0b013e318194515c] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few prospective trials in human leukocyte antigen (HLA) identical living donor (LD) renal transplantation exist. This prospective study evaluated a corticosteroid (CS)-free, calcineurin inhibitor (CNI) minimization immunosuppressive regimen in HLA-identical LD renal transplant recipients. METHODS Twenty HLA-identical LD recipients were prospectively enrolled. Immunosuppression included mycophenolate mofetil (MMF) (2 g/day), tacrolimus (target trough 4-8 ng/mL), sirolimus (target trough 6-10 ng/mL), and no pre- or postoperative steroids. In the absence of prior rejection, tacrolimus was discontinued at posttransplant day 120 and sirolimus at 1 year, leaving patients on MMF monotherapy. RESULTS Tacrolimus was successfully withdrawn in 94% of patients (16/17). One hundred percent (15/15) of patients who reached 1-year posttransplant had sirolimus discontinued. Ninety-four percent (17/18) of patients remain off CSs. Mean serum creatinine at 6, 12, and 24 months were 1.38+/-0.32, 1.35+/-0.37, and 1.25+/-0.29 mg/dL; corresponding mean calculated creatinine clearance estimates were 70+/-18, 73+/-17, and 72+/-15 mL/min. Acute cellular rejection, chronic allograft nephropathy, and CNI toxicity were not observed. Death-censored graft survival was 100% at last follow-up. CONCLUSIONS A CS-free, CNI minimization immunosuppressive regimen with weaning to MMF monotherapy provides excellent renal function, graft survival, and patient survival in HLA-identical LD renal transplant recipients.
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Keitel E, Santos AF, Alves MA, Neto JP, Schaefer PG, Bittar AE, Goldani JC, Pozza R, Bruno RM, See D, Garcia CD, Garcia VD. Immunosuppression protocols for HLA identical renal transplant recipients. Transplant Proc 2003; 35:1074-5. [PMID: 12947863 DOI: 10.1016/s0041-1345(03)00313-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- E Keitel
- Renal Transplant Unit, Santa Casa Hospital, Porto Alegre, RS, Brazil.
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