An audit conducted earlier in our unit on renal transplant recipients (RTR) revealed a higher rate (30%) of acute rejection (AR) episodes. Subsequently we conducted a prospective study with a modified immunosuppression (IS) protocol for RTR and the results are presented here.
Methodology: -75 renal transplants were performed over 8 months following the audit and the subjects were prospectively studied on a new IS regime of - a) prednisolone 1.5 mg /Kg/day initially and then gradually tapered, b) mycophenolate mofetil (MMF) 1gm twice daily from 3 days pretransplant, c) alternate patients started on cyclosporin (CyA) or tacrolimus one day pretransplant, as compared to the previous IS protocol of prednisolone 1mg/kg/day, MMF 1gm twice daily from 2 days pretransplant and all subjects on CyA one day pretransplant. Induction IS was continued as before with either antithymocyte globulin (ATG) or interleukin 2-receptor antibody (IL2Rab). Dosage adjustments were promptly made to ensure maintenance of adequate blood levels of CyA (C2) and tacrolimus. AR episodes were documented and treated as per standard protocol. 7 episodes of AR occurred in a total of 75 RTR (9.3%) in the first 3 months post transplant. There was no significant difference in AR episodes between subjects who received CyA (6.25%) and those who received tacrolimus (8.3%). Cadaver donor recipients had a higher rate of AR (19%) compared to live donor recipients (7.3%) and subjects with 4 or more HLA mismatches showed a higher AR rate (13.4%) compared to those with less mismatches (4.1%). Pediatric recipients had higher AR rates (30.7%) compared to adult recipients (6.3%). All subjects achieved adequate CyA (C2) and tacrolimus blood levels. There was a significant reduction in AR rates with the modified IS protocol (30% -> 9.3%). Higher dose of steroids, earlier adequate doses of MMF and scrupulous maintenance of adequate CyA and tacrolimus levels reduced the rates of AR. Higher HLA mismatches, cadaver donors and pediatric recipients had higher AR episodes.