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 c ould be even more suitable for 'immunologically advantaged' grafts as in li ve related renal transplantation. We report the long-term outcome of patien ts in a live related transplantation programme undergoing early (between 19 89 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 patient s were divided into three groups based on the following immunosuppressive p rotocol: group ECyW (n = 99), early CsA withdrawal (9 months after transpla ntation); group LCyW (n = 44), late CsA withdrawal (median 16 months, range 13-22 months after transplantation); and group LDCy (n = 109), long-term l ow dose CsA. The median period of follow-up was 66 months after transplanta tion (range 43-84 months). There was no difference in the actuarial 6-yr pa tient or graft survival among the three groups. Acute rejection episodes we re 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) ac ute 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 patient s who developed acute rejection episodes after CsA withdrawal, 13 (40.6%) l ost their grafts either due to uncontrolled acute rejection or to chronic r ejection. Chronic rejection was higher in ECyW (24%) than in LCyW (11%; p = 0.04) and LDCy (17%; p = 0.17). Antihypertensive requirement was highest i n 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 Cs A 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 admini stration of low dose CsA.