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Increased Early Rejection Rate after Conversion from Tacrolimus in Kidney and Pancreas Transplantation

Context A successful immunosuppression regimen for combined kidney and pancreas transplants is tacrolimus, mycophenolate mofetil, and prednisone. However, not allpatients tolerate these immunosuppressants especially tacrolimus. Objective To evaluate the efficacy of cyclosporine as a rescue agent for tacrolimus toxicity in combined kidney and pancreas transplants. Design Retrospective. Setting :Single center. Patients Thirty-five combined kidney and pancreas transplants were performed between July 1994 and January 1999. All patients were insulin dependent diabetics with end-stage renal disease. Twenty-eight (mean age: 36 years and 57% female) were available with at least 12 month follow-up. Interventions Conversion to cyclosporine following renal (biopsy proven) or pancreaticdysfunction. Main outcome mearsures Toxicity, rejectionrate, and patient/transplant organ survival. Results Nineteen transplant recipients (68%) were continuously maintained on tacrolimus while nine (32%) required conversion to cyclosporine 75±20 days post-transplant. Reasons for conversion included: hyperglycemia (n=2), hemolytic-uremic syndrome (n=1), and severe tacrolimus nephrotoxicity (n=6). By 12 months posttransplant, the 19 patients maintained ontacrolimus had 5 rejections (26%). Three of the 9 patients (33%) converted to cyclosporine had an acute rejection prior to conversion. Seven of these 9 patients (78%; P=0.017 vs. patients maintained on tacrolimus) had rejections an average of 25±4 days post-conversion. Four of the 7 patients had no previous rejections prior to conversion. In spite of increased rejections, the 1- and 2-year patient/graft survivals were unchanged by converting. Conclusions Converting to cyclosporine from tacrolimus was associated with an increased risk of acute rejection especially within the first 30 days post conversion.


Gary W Barone, Beverley L Ketel, Sameh R Abul-Ezz, Meredith L Lightfoot

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