Treatment protocol consisted of induction with Daclizumab and maintenance protocol of CSA/MMF/prednisone for the first two weeks of engraftment followed by CSA withdrawal and introduction of Rapamycin. Target Rapamycin trough levels were 15-25 ng/L. Steroids are withdrawn at 3-6 months post engraftment. In the event of acute clinical or subclinical rejection post conversion to Rapamycin, patients are crossed over to Tacrolimus. Response of clinical and subclinical rejection to therapy was monitored by clinical parameters and follow up renal biopsies. In a pilot study, 26 LRRTR were enrolled and at the time of this interim analysis, 19 patients have undergone conversion to Rapamycin and steroid withdrawal.

ACR*	ASR*	FUCr	FU	FUSW***
N= 19	Months	mmol/L	months
4 (21%)	5 (26%)	10 (5-16)	100 (80-132)	4 (1-13)

*ACR: Acute clinical rejection, **ASR: Acute subclinical rejection, ***FUSW: Follow up since steroid withdrawal

7/9 (80%) rejection episodes developed prior to steroid withdrawal. All rejection episodes were classified as Banff IA-IB. All patients with rejection were crossed over to Tacrolimus and all but one rejection episode resolved completely without maintenance steroids.
With careful monitoring for clinical and subclinical rejections, steroids can be withdrawn successfully in LRRTR, following the above graded approach to immunosuppressive protocol. Tacrolimus/MMF combination appears to be more efficacious in achieving the goal of successful steroid withdrawal.