Greg Knoll1, Patricia Campbell2, Michaël Chassé3, Dean Fergusson4, Tim Ramsay4, Priscilla Karnabi4, Jeffrey Perl5, Andrew A House6, Joseph Kim7, Olwyn Johnston8, Rahul Mainra9, Isabelle Houde10, Dana Baran11, Darin J Treleaven12, Lynne Senecal13, Lee Anne Tibbles14, Marie-Josée Hébert15, Christine White16, Martin Karpinski17, John S Gill18. 1. University of Ottawa, Department of Medicine (Nephrology) and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. 2. Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada. 3. Department of Medicine (Critical Care), University of Montreal Hospital, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada. 4. Clinical Epidemiology Program, the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. 5. Division of Nephrology, St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. 6. Western University, Department of Medicine (Nephrology) and the London Health Sciences Centre, London, Ontario, Canada. 7. Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology and the Ajmera Transplant Centre, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. 8. University of British Columbia, Division of Nephrology, Vancouver General Hospital, Vancouver, British Columbia, Canada. 9. Saskatchewan Transplant Program, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. 10. Transplantation Unit, Renal Division, Department of Medicine, University Health Centre of Quebec, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada. 11. Division of Nephrology and the Multi-Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada. 12. Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. 13. Department of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada. 14. Southern Alberta Transplant Program, Department of Medicine, University of Calgary, Calgary, Alberta, Canada. 15. University of Montreal Hospital Research Centre and University of Montreal, Montreal, Quebec, Canada; Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Department of Medicine, University of Montreal, Montreal, Quebec, Canada. 16. Department of Medicine, Queen's University, Kingston, Ontario, Canada. 17. Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. 18. University of British Columbia Division of Nephrology, St. Paul's Hospital, Vancouver, British Columbia, Canada jgill@providencehealth.bc.ca.
Abstract
BACKGROUND: Patients with kidney transplant failure have a high risk of hospitalization and death due to infection. The optimal use of immunosuppressants after transplant failure remains uncertain and clinical practice varies widely. METHODS: This prospective cohort study enrolled patients within 21 days of starting dialysis after transplant failure in 16 Canadian centers. Immunosuppressant medication use, death, hospitalized infection, rejection of the failed allograft, and anti-HLA panel reactive antibodies were determined at 1, 3, 6, and 12 months and and then twice yearly until death, repeat transplantation, or loss to follow-up. RESULTS: The 269 study patients were followed for a median of 558 days. There were 33 deaths, 143 patients hospitalized for infection, and 21 rejections. Most patients (65%) continued immunosuppressants, 20% continued prednisone only, and 15% discontinued all immunosuppressants. In multivariable models, patients who continued immunosuppressants had a lower risk of death (hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.17 to 0.93) and were not at increased risk of hospitalized infection (HR, 1.81; 95% CI, 0.82 to 4.0) compared with patients who discontinued all immunosuppressants or continued prednisone only. The mean class I and class II panel reactive antibodies increased from 11% to 27% and from 25% to 47%, respectively, but did not differ by immunosuppressant use. Continuation of immunosuppressants was not protective of rejection of the failed allograft (HR, 0.81; 95% CI, 0.22 to 2.94). CONCLUSIONS: Prolonged use of immunosuppressants >1 year after transplant failure was not associated with a higher risk of death or hospitalized infection but was insufficient to prevent higher anti-HLA antibodies or rejection of the failed allograft.
BACKGROUND: Patients with kidney transplant failure have a high risk of hospitalization and death due to infection. The optimal use of immunosuppressants after transplant failure remains uncertain and clinical practice varies widely. METHODS: This prospective cohort study enrolled patients within 21 days of starting dialysis after transplant failure in 16 Canadian centers. Immunosuppressant medication use, death, hospitalized infection, rejection of the failed allograft, and anti-HLA panel reactive antibodies were determined at 1, 3, 6, and 12 months and and then twice yearly until death, repeat transplantation, or loss to follow-up. RESULTS: The 269 study patients were followed for a median of 558 days. There were 33 deaths, 143 patients hospitalized for infection, and 21 rejections. Most patients (65%) continued immunosuppressants, 20% continued prednisone only, and 15% discontinued all immunosuppressants. In multivariable models, patients who continued immunosuppressants had a lower risk of death (hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.17 to 0.93) and were not at increased risk of hospitalized infection (HR, 1.81; 95% CI, 0.82 to 4.0) compared with patients who discontinued all immunosuppressants or continued prednisone only. The mean class I and class II panel reactive antibodies increased from 11% to 27% and from 25% to 47%, respectively, but did not differ by immunosuppressant use. Continuation of immunosuppressants was not protective of rejection of the failed allograft (HR, 0.81; 95% CI, 0.22 to 2.94). CONCLUSIONS: Prolonged use of immunosuppressants >1 year after transplant failure was not associated with a higher risk of death or hospitalized infection but was insufficient to prevent higher anti-HLA antibodies or rejection of the failed allograft.
Authors: Michael J Casey; Xuerong Wen; Liise K Kayler; Ravi Aiyer; Juan C Scornik; Herwig-Ulf Meier-Kriesche Journal: Transplantation Date: 2014-08-15 Impact factor: 4.939
Authors: Michelle Lubetzky; Ekamol Tantisattamo; Miklos Z Molnar; Krista L Lentine; Arpita Basu; Ronald Parsons; Kenneth J Woodside; Martha Pavlakis; Christopher Blosser; Neeraj Singh; Beatrice P Concepcion; Deborah Adey; Garauv Gupta; Arman Faravardeh; Edward Kraus; Song Ong; Leonardo Riella; John Friedewald; Alex Wiseman; Amtul Aala; Darshana M Dadhania; Tarek Alhamad Journal: Am J Transplant Date: 2021-06-11 Impact factor: 8.086
Authors: Marco Bonani; Rita Achermann; Harald Seeger; Michael Scharfe; Thomas Müller; Stefan Schaub; Isabelle Binet; Uyen Huynh-Do; Suzan Dahdal; Dela Golshayan; Karine Hadaya; Rudolf P Wüthrich; Thomas Fehr; Stephan Segerer Journal: Nephrol Dial Transplant Date: 2020-12-04 Impact factor: 5.992