Lessons from cyclosporine monotherapy in renal transplantation: the impact of acute rejection on long-term allograft outcome.

UNLABELLED: The introduction of cyclosporine in kidney transplantation rapidly improved short and medium term graft and patient survival rates. Initially many trials used cyclosporine monotherapy to avoid steroid toxicity, but high acute rejection rates lead to a change in the immunosuppressant scheme. The use of prophylactic steroids significantly decreased acute rejection rates, but the long-term benefit of such a reduction has not been assessed.

METHODS: Retrospective analysis of the impact of early acute rejection on long-term outcome (10 years) in 264 consecutive renal transplants performed in a single institution between 1986 and 1993 using cyclosporine monotherapy (CM) (n=139) versus cyclosporine and prednisone (CS) (n=125). Different protocols were used for elderly or immunological high-risk patients and for transplants with delayed graft function and therefore these patients are not included. The incidence and severity of acute rejection episodes and long-term patient and graft survivals were analyzed.

RESULTS: At 1 year, acute rejection episodes showed significantly higher frequency in the CM group than in the CS group (72.66% vs 46.40%). Nevertheless, graft and patient survival rates were similar at 1, 5, and 10 years (Graft: 96.38%, 78.77%, and 59.84% vs 92.59%, 75.62%, and 53.44%;

PATIENT: 99.27%, 95.06%, and 84.76% and 95.9%, 93.09%, and 88.28%).

CONCLUSION: The addition of prophylactic steroids decreases the incidence of acute rejection but does not improve the long-term graft survival. These findings suggest that in an era of new immunosuppressants, fewer acute rejection episodes will be evident requiring more effort to detect and treat subclinical rejections.