ELECTIVE CYCLOSPORINE WITHDRAWAL 1 YEAR AFTER RENAL-TRANSPLANTATION

Whether the risks of acute rejection after elective cyclosporine (CsA) withdrawal in renal transplantation outweigh the potential benefits i s unclear. We examined results for 236 patients who underwent transpla ntation between January 1986 and June 1991. Patients were treated with prophylactic CsA, prednisone, and azathioprine, and had grafts that f unctioned at least 1 year. We elected to withdraw CsA after 1 year in 192 patients who were rejection free for 12 months. Thirty-four patien ts elected to continue CsA. In 1988 a protocol that tapered CsA over 6 weeks was abandoned when eight (29.6%) of the first 27 patients devel oped acute rejection within 6 months. We then adopted a 12-week CsA ta per preceded by 1 month of increased azathioprine (2.5 mg/d as tolerat ed) and followed by increased prednisone (30 mg/d for 1 week, 20 mg/d for 1 week, 15 mg/day for 6 months, then 15 mg/d on alternate days). W ith this protocol the incidence of postwithdrawal acute rejection with in 6 months was reduced to 9.1% among 165 patients (P < 0.01 v 6-week taper). Actuarial 5-year graft survival (patients living with a functi oning graft) was 81.7% for patients left on CsA, 88.9% for patients ta pered over 6 weeks, and 81.5% for patients tapered over 12 weeks (P > 0.05). We also examined risk factors for acute rejection after CsA wit hdrawal using a Cox proportional hazards model and found that the rela tive risk of acute rejection within 6 months of taper was approximatel y two times greater for each DR mismatch (P < 0.001). We conclude that CsA withdrawal has not affected renal allograft survival at our cente r. Moreover, the risk of acute rejection following CsA withdrawal was proportional to the number of DR mismatches, suggesting that an emphas is on major histocompatibility complex matching may reduce the need fo r long-term CsA. (C) 1994 by the National Kidney Foundation, Inc.