By Will Boggs, MD
NEW YORK (Reuters Health) – Immunosuppression should be halted in patients whose renal transplants have failed and who have returned to dialysis, according to a report in the December 2001 issue of Clinical Transplantation.
Few studies have addressed the management of patients who return to dialysis after failure of a renal allograft, the authors explain, so it is unclear whether immunosuppression initiated to prevent rejection should be continued.
Dr. P. J. H. Smak Gregoor, from University Hospital Rotterdam-Dijkzigt in Rotterdam, the Netherlands, and colleagues evaluated the effects of continued immunosuppression in 192 patients with the outcomes of 90 comparable patients in whom immunosuppression was discontinued. The number and rate of acute rejections did not differ between the groups, the report indicates.
Infectious complications were 3.4-fold higher among patients continuing immunosuppression, the authors note, regardless of whether the infections were bacterial (3.3-fold increase), viral (7.7-fold increase), or opportunistic (45.3-fold higher).
Infection-related mortality was nearly three times higher in the group continuing immunosuppression, the results indicate.
Cardiovascular morbidity was also three times higher in the immunosuppressed group, the researchers note, and death from cardiovascular causes was increased nearly 5-fold.
The overall death rate, in fact, was 3.4 times higher (0.22 deaths per patient year versus 0.07 deaths per patient year, p < 0.0001) in the patients who continued immunosuppression, compared with those who did not, the investigators report.
"Even low-dose immunosuppression in patients after renal allograft failure puts the patient at increased risk for serious, even life-threatening infections and an increased risk for cardiovascular disease," Dr. Smak Gregoor told Reuters Health.
"The results of our study strongly favor a policy of tapering and stopping immunosuppressive drugs as quickly as feasible," the authors conclude.
Some patients should continue to receive immunosuppressive therapy, Dr. Smak Gregoor said, including "patients with an immunological disease which led to renal insufficiency, such as SLE [systemic lupus erythematosus], who require immunosuppression to prevent flare-ups of their original disease after renal graft failure."
Dr. Smak Gregoor added: "Transplantectomy should be performed only if, after discontinuation of immunosuppression, clinical signs of acute rejection occur. This [is] to avoid unnecessary morbidity or even mortality related to surgery. It is possible to have a failed renal allograft in situ without acute rejection and without immunosuppression."
Clin Transplant 2001;15:397-401.
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