A single center's clinical experience with quadruple immunosuppression including ATG or IL2 antibodies and mycophenolate mofetil in simultaneous pancreas-kidney transplants

Acute rejection remains a major problem in simultaneous pancreas-kidney (SP K) transplant and occurs in 60-100% of the cases. With the introduction of mycophenolate mofetil (MMF) replacing azathioprine (AZA) as a basis immunos uppressant, reduced rates of rejection have been reported. This study inves tigates the frequency and clinical relevance of allograft rejection in SPK patients receiving antithymocyte globulin (ATG) or Basiliximab(R) induction therapy and cyclosporine Neoral(R) (CyA), MMF, steroid basis immunosuppres sion. Between December 1996 and October 1999, 21 consecutive patients (15 m ales, 6 females) received a SPK transplant at our institution with a mean /- standard deviation (SD) age of 42 +/- 6 yr. Of these, 14 patients were t reated with anti-thymocyte globulin (ATG) Fresenius(R) (rabbit) 3-5 mg/kg f or 6 +/- 2 d, cyclosporine Neoral (CyA) (trough levels 350-400 ng/mL), MMF 3 g/d and low dose steroid therapy. Seven SPK patients were treated with Ba siliximab (Simulect(R), Novartis 20 mg on d 0 and d 4 post-transplant) inst ead of ATG. The patients had an average human leucocyte antigen (HLA) misma tch of 3.9/6 and a negative cross match. All patients remained on triple dr ug therapy. Three patients were switched to tacrolimus instead of Neoral fo r CyA intolerance. The mean +/- SD cold ischemia time (CIT) of the organs w as 10.1 +/- 2.4 h for the pancreas and 10.5 +/- 2.6 h for the kidney. Results: Biopsy-proven rejection occurred in the kidney of 1 ATG patient (8 %), which responded to steroid bolus therapy. One of the patients (14%) wit h Basiliximab induction developed renal allograft rejection, which was reso lved after a 6-d course of anti-CD3 mAb (OKT3) treatment. All patients (100 %) were free from rejection in the pancreas, as measured by urine amylase l evels and glycemic control without the need for exogenous insulin with a me an glycosylated hemoglobin (HBA(1)C) of 5.1 +/- 0.7% and serum creatinine w ith a mean of 1.24 +/- 0.24 mg/dL in a mean follow-up period of 17 +/- 15 m onths (median 12, range 2-37). Conclusion: Triple drug immunosuppression including cyclosporine, MMF and l ow dose steroids with ATG or interleukin 2 (IL2) receptor antibodies induct ion therapy appears to be a very suitable immunosuppressive regimen for com bined pancreas-kidney transplant (PKT) with a marked reduction in the incid ence of rejection.