THERAPEUTIC STRATEGIES FOR KIDNEY TRANSPLANTATION

H.P. Tan¹, A. Chaudhary², A. Humar³, J. Donaldson¹, A. Basu¹, C. Morgan¹, M. Unruh⁴, J. Mccauley⁴, C. Wu⁴, N. Shah⁵, P. Randhawa⁶, R. Shapiro^1
1Surgery / Transplant, Thomas E. Starzl Transplantation Institute, Pittsburgh/PA/UNITED STATES OF AMERICA, ²Transplant Surgery, Thomas E. Starzl Transplantation Institute, Pittsburgh/PA/UNITED STATES OF AMERICA, ³Department Of Surgery, Thomas E. Starzl Transplantation Institute, Pittsburgh/PA/UNITED STATES OF AMERICA, ⁴Nephrology, UPMC, Pittsburgh/PA/UNITED STATES OF AMERICA, ⁵Internal Medicine/nephrology, UPMC, Pittsburgh/PA/UNITED STATES OF AMERICA, ⁶Pathology, UPMC, Pittsburgh/PA/UNITED STATES OF AMERICA

Body: Introduction: Living donor kidney transplantation (LDKT) was performed under a regimen of recipient pretreatment (alemtuzumab) and minimal post-transplant immunosuppression(tacrolimus monotherapy) with subsequent weaning.
Methods: We performed 200 consecutive unselected living donor kidney transplants (donor kidneys were removed laparoscopically) from 03/14/2003 to 12/12/2005 using 30 mg (or 0.4 to0.5mg/kg) alemtuzumab and tacrolimus monotherapy. At 6 months post-transplant and every 2 to 6 months interval, we used clinical data (including ELISA antibody titers, Cylex and Luminex) to weantacrolimus when possible (bid-->qd-->qod-->tiw-->biw-->qwk. Spaced weaning was put on temporary hold beginning in Mar 2007). The recipients included 4 HIV+, 17 pediatric patients, and23 re-transplants. The mean follow up was 59.7+13.6 months.
Results: Actuarial recipient survivals at 1-, 2-, 3-, 4-, and 5-years were 99.0%, 97.0%, 94.9%, 92.4%, 90.0%, respectively. Graft survivals at 1-, 2-, 3-, 4-, and 5-years were 98.0%,90.5%, 87.5%, 81.0%, and 77.7% respectively. The mean GFR (mL/min/1.73m2) at 1-, 2-, 3-, 4-, and 5-years was 59±22, 55±21, 55±21, 57±22, and 55±24 respectively. Thecumulative incidence of biopsy-proven acute cellular rejection (ACR) at 1, 3, 6, 12, 18, 24, 30, 36, 42, 48, 54, and 60 months were 1.0%, 1.0%, 2.0%, 9.0%, 16.5%, 19.5%, 24.0%, 24.5%, 28.0%, 29.0%,30.0%, and 31.0% respectively. 77.0% of recipients had been weaned to spaced-dose (qod or less) tacrolimus monotherapy. 88.7% of ACR were Banff 1 and of these 82% were sensitive to steroid pulses. Atleast ten had AMR (with DSA and C4d) and received IVIg and plasmapheresis. 90% of recipients are still steroid-free. There was no DGF or CMV disease, and the incidence of post-transplant insulindependent diabetes mellitus was 0.5%. One (0.5%) patient developed PTLD 17 months post transplantation on every other day tacrolimus. Because protocol biopsies were not performed, we could not makeany definitive conclusion in the limited IF/TA data.
Conclusion: This report represents a large series with the longest mean follow-up (5 years) of LDKT under alemtuzumab pretreatment with tacrolimus monotherapy, and confirms the5-year safety and efficacy of this novel approach.

Disclosure: All authors have declared no conflicts of interest.