Prevention of acute rejection with antithymocyte globulin, avoiding corticosteroids, and delaying cyclosporin after renal transplantation

Background, Despite their well-known side-effects, corticosteroids (Cs) are currently used after kidney transplantation. avoidance of Cs may improve p atient quality of life and eventual long-term survival. We report on a regi men using antithymocyte globulin (ATG) and mycophenolate mofetil (MMF) for induction, and cyclosporin (CsA) plus MMF for maintenance treatment of reci pients of primary kidney transplantation. Methods. We studied 11 consecutive, non-sensitized renal transplant patient s (nine cadaver and two living donors). Initial immunosuppression consisted of ATG (1.5 mg/kg/day, i.v.) given for 10 days and MMF (1.0 g/b.i.d.). CsA (8 mg/kg, in two divided doses) was started on post-operative day 11. Cs w ere only allowed in the case of MMF discontinuation, for the treatment of a cute rejection, and in the event of recurrence of the primary glomeruloneph ritis. Results. All patients completed the entire 10-day ATG course. Main side-eff ects included fever (> 38 degrees C) and serum sickness, observed in 73 and 27% of the patients respectively. The incidence of acute rejection was 27% (three of 11 patients). In two patients with acute rejection, serum sickne ss was concomitantly diagnosed and renal histology was partially compatible with immune-complex disease. The remaining patient had two episodes of low -grade rejection. All rejection episodes were rapidly reversed. Two patient s (18%) were treated with ganciclovir for cytomegalovirus (CMV) infection. Two patients (18%) are currently receiving Cs for recurrence of the native glomerulonephritis and two rejection episodes respectively. All patients ar e currently alive with functioning kidneys (average follow-up of 8.4 months ; average creatinine level of 128 mu mol/l). Conclusion. This pilot study suggests that ATG induction in combination wit h MMF and delayed introduction of CsA, in the absence of Cs, is not well to lerated in recipients of kidney transplants. An earlier introduction of cal cineurin inhibitors and/or a shorter course of ATG may reduce the incidence of fever and serum sickness secondary to ATG.