Steroid Sparing Maintenance Immunosuppression in Highly Sensitised Patients Receiving Alemtuzumab Induction.
In 120 highly sensitised kidney transplant recipients given alemtuzumab induction with steroid-sparing maintenance, tacrolimus plus mycophenolate mofetil achieved markedly better rejection-free survival than tacrolimus monotherapy, supporting steroid avoidance with dual maintenance in this high-risk group.
Background
Highly sensitised patients (calculated reaction frequency over 85%) are among the most immunologically challenging kidney transplant candidates, traditionally managed with intensive immunosuppression including steroids. Alemtuzumab induction enables steroid-sparing maintenance, but the optimal maintenance backbone in sensitised recipients has been uncertain. This analysis compared two steroid-sparing protocols to inform steroid avoidance in this population.
Study design
The analysis reported outcomes of 120 highly sensitised patients receiving alemtuzumab induction, with 53 maintained on tacrolimus monotherapy and 67 on tacrolimus plus mycophenolate mofetil. The two groups had similar median calculated reaction frequency and mode of sensitisation, although the combination cohort received more poorly matched grafts. Immunological and infectious complications were examined in detail.
Key findings
One-year patient and allograft survival did not differ between groups, and donor-specific antibody-free survival was comparable. However, rejection-free survival was inferior with tacrolimus monotherapy compared with tacrolimus plus mycophenolate mofetil (65.4% versus 91.4%). CMV-free survival was lower in the combination group (86.0% versus 98.1%), and post-transplant diabetes-free survival was 89.6% with monotherapy versus 100.0% with combination therapy, the difference attributed to prednisolone used to treat rejection in the monotherapy cohort.
Clinical implications
The data support a steroid-sparing protocol of alemtuzumab induction with tacrolimus plus mycophenolate mofetil maintenance as effective in highly sensitised recipients, with superior protection against rejection. The trade-off is a higher CMV burden with the combination, underscoring the need for vigilant viral monitoring and prophylaxis when intensifying maintenance immunosuppression in these patients.
Category
Transplant
Source
Transpl Int
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