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Budde K, Zeier M, Witzke O, Arns W, Lehner F, Guba M, Jacobi J, Kliem V, Reinke P, Hauser IA, Vogt B, Stahl R, Rath T, Duerr M, Paulus EM, May C, Porstner M, Sommerer C. Everolimus with cyclosporine withdrawal or low-exposure cyclosporine in kidney transplantation from Month 3: a multicentre, randomized trial. Nephrol Dial Transplant 2018; 32:1060-1070. [PMID: 28605781 DOI: 10.1093/ndt/gfx075] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/04/2017] [Indexed: 12/30/2022] Open
Abstract
Background. Randomized trials have shown that early adoption of everolimus-based immunosuppressive regimens without a calcineurin inhibitor (CNI) improves long-term kidney graft function, but the optimal strategy for CNI minimization remains uncertain. Methods. In a prospective, randomized, multicentre, 12-month trial, 499 de novo kidney transplant patients were randomized at Month 3 to (i) remain on standard CNI (cyclosporine) therapy with mycophenolic acid, (ii) convert to everolimus with mycophenolic acid or (iii) start everolimus with reduced CNI and no mycophenolic acid (clinical trials registry: ClinicalTrials.gov-NCT00514514). Results. The primary endpoint, change in estimated glomerular filtration rate (eGFR) (Nankivell) from randomization to Month 12, was significantly greater in the CNI-free arm versus standard CNI therapy: mean difference 5.6 mL/min/1.73 m 2 [95% confidence interval (CI) 2.8-8.3 mL/min/1.73 m 2 , P < 0.001]. The improvement in eGFR in the CNI-free arm was also higher than in the low-CNI group (mean difference 5.5 mL/min/1.73 m 2 , 95% CI 2.8-8.2 mL/min/1.73 m 2 , P < 0.001), while results were similar in the low-CNI and standard CNI arms. The post-randomization incidence of biopsy-proven acute rejection was 11.7%, 8.1% and 7.9% in the CNI-free, low-CNI and standard CNI groups, respectively (CNI-free versus standard CNI, P = 0.27; low-CNI versus standard CNI, P = 1.00). Adverse events led to study drug discontinuation in 28.7%, 15.5% and 15.2% of CNI-free, low-CNI and standard CNI patients, respectively. Conclusions. Everolimus initiation with CNI withdrawal at Month 3 after kidney transplantation achieves a significant improvement in renal function at 12 months, with a similar rate of acute rejection.
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Affiliation(s)
- Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Oliver Witzke
- Department of Infectious Diseases and Department of Nephrology, University Duisburg-Essen, Essen, Germany
| | - Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Centre, Cologne, Germany
| | - Frank Lehner
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Markus Guba
- Department of General, Visceral and Transplantation Surgery, Munich University Hospital, Campus Grosshadern, Munich, Germany
| | - Johannes Jacobi
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Volker Kliem
- Department of Internal Medicine and Nephrology, Kidney Transplant Centre, Nephrological Centre of Lower Saxony, Klinikum Hann. Münden, Germany
| | - Petra Reinke
- Department of Nephrology and Intensive Care, Charité Campus Virchow, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ingeborg A Hauser
- Department of Nephrology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Bruno Vogt
- Department of Nephrology and Hypertension, Inselspital, Bern, Switzerland
| | - Rolf Stahl
- III. Medical Clinic, University Hospital Hamburg, Hamburg, Germany
| | - Thomas Rath
- University Hospital Westpfalz, Kaiserslautern, Germany
| | - Michael Duerr
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Claudia Sommerer
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
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