Cyclosporin A withdrawal in live related renal transplantation: long-term results

Cyclosporin A (CsA) withdrawal after I yr of stable graft function has been shown to be beneficial in cadaveric renal transplantation. This strategy could be even more suitable for 'immunologically advantaged' grafts as in live related renal transplantation. We report the long-term outcome of patients in a live related transplantation programme undergoing early (between 1989 and 1992) and late (1993 onwards) CsA withdrawal as compared with those on long-term low dose CsA (1993 onwards). Two-hundred and fifty-two patients were divided into three groups based on the following immunosuppressive protocol: group ECyW (n = 99), early CsA withdrawal (9 months after transplantation); group LCyW (n = 44), late CsA withdrawal (median 16 months, range 13-22 months after transplantation); and group LDCy (n = 109), long-term low dose CsA. The median period of follow-up was 66 months after transplantation (range 43-84 months). There was no difference in the actuarial 6-yr patient or graft survival among the three groups. Acute rejection episodes were more frequent in ECyW (54.4%) than in LDCy (31.8%) and LCyW (23.8%) (p = 0.001). The risk of developing late (greater than or equal to 9 months) acute rejection was highest in ECyW 32/99 (32.3%) as compared with LCyW 8/44 (18.4%; p = 0.08) and LDCy 8/109 (7.3%; p = 0.0001). Of the 32 ECyW patients who developed acute rejection episodes after CsA withdrawal, 13 (40.6%) lost their grafts either due to uncontrolled acute rejection or to chronic rejection. Chronic rejection was higher in ECyW (24%) than in LCyW (11%; p = 0.04) and LDCy (17%; p = 0.17). Antihypertensive requirement was highest in patients maintained on low dose CsA, Graft function, as measured by serum creatinine levels, was significantly better in LCyW (1.24 +/- 0.4 mg%) as compared with ECyW (1.49 +/- 0.5 mg%) and LDCy (1.48 +/- 0.6 mg%). Early CsA withdrawal after live related renal transplantation is associated with a significant risk of acute rejection and subsequent chronic rejection. Slow withdrawal after 1 yr is safe and more economical than the long-term administration of low dose CsA.