New Recipes With Known Ingredients: Combined Therapy of Everolimus and Low-dose Tacrolimus in De Novo Renal Allograft Recipients T. Santosa,*, L. Santosa, F. Macárioa, C. Romãozinhoa, R. Alvesa, M. Camposa, and A. Motab a
Nephrology Department, CHUC, Coimbra, Portugal; and bUrology and Kidney Transplantation Department, CHUC, Coimbra, Portugal
ABSTRACT Background. Calcineurin inhibitors (CNIs) are the cornerstones of immunosuppressive management in renal allograft recipients even though their nephrotoxicity may contribute to a reduced long-term graft survival. This has created a great interest in improving immunosuppressive strategies in the early post-transplantation period. Proliferation signal inhibitors (PSIs), such as everolimus, are promising alternatives, although their side effects may have a drawback in de novo renal transplant recipients, for instance, delaying renal function in the presence of renal ischemia/acute tubular necrosis and predisposing to lymphocele development. Study and Methods. A retrospective study was developed to compare the combined therapy of low-dose tacrolimus and everolimus (study group) with mycophenolate mofetil/ mycophenolic acid and standard-dose tacrolimus (control group) in the first 3 months posttransplantation. The study’s end-points concerned renal graft function, proteinuria, incidence of biopsy-proven acute rejection, surgical complication rates, and incidence of new-onset diabetes after renal transplantation. Results. There was no more delayed graft function in the study group and graft function distribution was similar between groups. Median serum creatinine and eGFR were comparable as well as proteinuria levels. Generally, adverse events were rare in both groups and there were no significant statistical differences between them in terms of biopsy-proven acute rejection, surgical complication, and new-onset diabetes after renal transplantation rates. Conclusion. Despite the slightly lower tendency for serum creatinine in the study group, renal allograft function wasn’t statistically different between groups. Moreover, there weren’t more metabolic or surgical complications in the study group. Everolimus may be a choice in tacrolimus-sparing strategies, but a larger study and a longer follow-up are still required.
O
VER the last several decades there have been significant improvements in immunosuppressive therapy regarding the acute rejection rates achieved in the first year post-transplantation. However, long-term renal allograft survival has only marginally improved and remains a challenge [1e3]. Chronic allograft nephropathy (CAN, histologically described as interstitial fibrosis and tubular atrophy) is the main cause of graft failure and multiple factors account for it (e.g. calcineurin inhibitor (CNI) nephrotoxicity, donor age, graft quality, and comorbidities) [3e8]. CNIs have been the cornerstones of the immunosuppressive management in renal allograft recipients because of 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.03.042
906
their efficacy in preventing acute rejections. However, they are pleomorphic nephrotoxins and their long-term use contributes to the development of CAN and therefore compromising outcomes [5,7e9]. In addition, patients receiving CNIs have an increased risk of developing cardiovascular events and new-onset diabetes after transplantation (NODAT) [8e10]. Consequently, there has been strong *Address correspondence to Tânia Santos, Nephrology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-075 Coimbra, Portugal. E-mail: [email protected] ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 906e910 (2015)
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907
Fig 1. Immunosuppressive protocols.
interest in developing new immunosuppressive regimens that improve long-term renal allograft survival rate while preserving renal function and without compromising immunosuppressive efficacy. Cyclosporine-sparing strategies using mycophenolate mofetil/mycophenolic acid or proliferation signal inhibitors (PSIs, also known as mammalian target of rapamycin inhibitors [mTORi]), such as sirolimus and everolimus, have demonstrated promising results [11e20]. Moreover, some studies [6,21,22] have pointed to the superiority of tacrolimus-based regimens when compared to cyclosporine-based ones, making tacrolimus the preferred CNI used in today’s clinical practice. Similarly, there has been growing interest in tacrolimus-sparing strategies, particularly those with everolimus [4,23]. Antiproliferative properties of everolimus may inhibit the underlying key mechanisms leading to CAN and ultimately improve longterm graft outcomes [24]. However, everolimus is associated with class specific adverse effects that may represent a drawback when considering them in de novo renal transplantation, such as delaying renal function recovery in the presence of renal ischemia/acute tubular necrosis, impairing wound healing with or without dehiscence and lymphocele development [20]. MATERIALS AND METHODS Study Design and Population This study analyzed retrospectively de novo renal transplant recipients from deceased heart beating donors between July 2013 and March 2014 that underwent 2 different immunosuppressive regimens: (1) tacrolimus 0.20 mg/kg/day plus acid mycophenolic/
mycophenolate mophetil plus prednisone (designated as control group) and (2) tacrolimus 0.15 mg/kg/day plus everolimus plus prednisone (designated as study group). All patients received a monoclonal antibody at day 0 and day 4 post-transplantation. A schematic illustration of the immunosuppressive protocols and immunosuppressor doses is provided in Fig 1. Patients submitted to living donor transplantation and those who received polyclonal antibodies were excluded. There was a 3-month follow-up period. In the study group the target trough levels for everolimus were 3e8 ng/ mL and for tacrolimus in the first month were 4e7 ng/mL and thereafter were 2e5 ng/mL. Tacrolimus target trough levels in the control group were 8e11 ng/mL. The aim of this study was to compare both groups in terms of (1) renal allograft function at discharge and the first, second, and third months post-transplantation; (2) incidence of biopsy-proven acute rejection (BPAR); (3) proteinuria levels at the first, second, and third months post-transplantation; (4) incidence of NODAT; and (5) incidence of surgical complications, such as lymphocele development (confirmed by ultrasonography and biochemical study), urinary leaks, and surgical wound dehiscence.
Statistical Methods Statistical analysis was made with SPSS Statistics version 22 (IBM, Chicago, Ill.,United States). Demographic and background characteristics used frequency (percentages) for qualitative variables and descriptive statistics with mean, standard deviation, median, minimum, and maximum for quantitative variables. The difference between groups was analyzed in terms of statistical significance. For quantitative variables with normal behavior, the Student t test was used, assuming equality of variances for a significance level > .05. For those without normal behavior, a Mann-Whitney test was performed. For qualitative nominal variables, c2 tests were applied.
908
SANTOS, SANTOS, MACÁRIO ET AL Table 1. Patient and Donor Demographics and Transplant Background Characteristics Control Group (n ¼ 34)
Variables
Patient demographics Age, mean years (SD) Male, n (%) Caucasian, n (%) Etiology of ESRD, n (%) Glomerulonephritis Hypertension/nephrosclerosis Polycystic renal disease Diabetes mellitus Unknown Number of HLA matches, n (%) Total (HLA 1) HLA-DR 1 PRA (most recent assessment), median % (minemax) Recipient CMV serologic status: CMV positive, n (%) Cold-ischemia time, mean hh:mm (SD) Donor demographics Age, median years (minemax) Age 60 years, n (%) Male, n (%) Cause of death Medical Traumatic
49.4 (12.7) 24 (70.6) 32 (94.1) 8 5 5 3 9 29 18 0.0 31 18:42
(23.5) (14.7) (14.7) (8.8) (26.5) (85.3) (52.9) (0.0e19.0) (91.1) (05:05)
Study Group (n ¼ 26)
P Value
48.2 (11.7) 15 (57.7) 26 (100.0)
.698* .299† .501† .382†
1 4 7 2 8 25 20 0.0 22 17:47
(3.8) (15.4) (26.9) (7.7) (30.8) (96.2) (76.9) (0.0e8.0) (85.6) (05:23)
53.0 (18e66) 8 (23.5) 12 (35.3)
53.0 (18e73) 5 (15.4) 17 (65.4)
22 (64.7) 12 (35.3)
16 (61.5) 10 (38.5)
.221† .056† .341‡ .454† .307‡ .638* .689† .021† .801†
Abbreviations: SD, standard deviation; ESRD, end-stage renal disease; HLA, human leucocyte antigen; CMV, cytomegalovirus; PRA, panel reactive antibody. *Student t test. † 2 c test. ‡ Mann-Whitney test.
RESULTS Patient and Donor Demographics
In total, 60 renal allograft recipients were analyzed: 34 were included in the control group and 26 in the study group. Patient and donor demographics and transplantation background characteristics were similar between groups (Table 1). Renal Function, Proteinuria, and BPAR Results
Immediate graft function (IGF) was seen in the majority of patients in both groups (Table 2). There was no more delayed graft function (DGF) in the study group. Instead, graft function distribution in terms of IGF, SGF, and DGF was similar between groups (P ¼ .426). Additionally, despite not having statistical significance, there was a propensity for a slightly better renal allograft function in the study group throughout the first 3 months post-transplantation as measured by serum creatinine and eGFR (MDRD) (Table 3). Proteinuria levels were comparable between groups (P ¼ .445, .780, and .383 at month 1, 2, and 3, respectively) with a Table 2. Renal Allograft Function Graft Function
IGF, n (%) SGF, n (%) DGF, n (%)
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value*
18 (52.9) 7 (20.6) 9 (26.5)
18 (69.2) 4 (15.4) 4 (15.4)
.426
Abbreviations: IGF, immediate graft function; SGF, slow graft function; DGF, delayed graft function. *c2 test.
constant median of 5 mg/dL. Despite having higher incidence of BPAR in the control group, the difference was not statistically significant (Table 3). Both cases occurred in the first 2 weeks post-transplantation in patients with concurrent nosocomial infections. Histologically they were classified as borderline AR (Banff, 2013) and favorably treated with corticosteroid pulses with a corresponding decline of serum creatinine. Tacrolimus and Everolimus Serum Trough Levels
On the third month tacrolimus trough level variation between groups achieved statistical significance, being lower in the study group, although not as low as we expected. Immunosuppressive trough levels during the follow-up period are detailed in Table 4. Adverse Events: Surgical Complications and NODAT Incidence
Globally, the incidence of adverse events was very low in both groups, with surgical complications being rare. Meanwhile the NODAT prevalence was 17.6% and 15.4% in the control and study group, respectively (Table 5). No patients died or lost their renal graft in the first 3 months post-transplantation. DISCUSSION
In Portugal, our center was the first to use an everolimusbased tacrolimus-sparing strategy. A retrospective analysis
EVEROLIMUS + LOW-DOSE TACROLIMUS THERAPY
909
Table 3. Evolution of Renal Allograft Function, Proteinuria, and BPAR Incidence in the First 3 Months Post-transplantation
Renal allograft function and proteinuria results Discharge SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Month 1 SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Proteinuria, median mg/dL (minemax) Month 2 SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Proteinuria, median mg/dL (minemax) Month 3 SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Proteinuria, median mg/dL (minemax) Acute rejection incidence, n (%)
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value
1.54 (0.75e2.98) 48.0 (19.0e107.0)
1.24 (0.63e4.09) 56.5 (11.0e102.0)
.123* .266*
1.37 (0.82e3.54) 50.0 (18.0e100.0) 5.0 (0.0e70.0)
1.29 (0.71e3.04) 62.5 (22.0e105.0) 5.0 (0.0e70.0)
.175* .156* .445*
1.34 (0.73e2.21) 54.5 (34.0e109.0) 5.0 (0.0e30.0)
1.23 (0.71e2.95) 58.0 (16.0e93.0) 5.0 (0.0e50.0)
.660* .748† .780*
1.31 55.0 5.0 2
1.18 57.0 5.0 0
.620† .697† .383* .501
(0.79e2.16) (36.0e96.0) (0.0e50.0) (5.9)
(0.71e2.13) (30.0e106.0) (0.0e70.0) (0.0)
Abbreviations: SCr, serum creatinine; SD, standard deviation; eGFR, estimated glomerular filtration rate; MDRD, modification of diet in renal disease 4-variable formula. *Mann-Whitney test. † Student t test.
was made, and the data collected from that experience allowed us to corroborate that this strategy has achieved good results in terms of renal function, its efficiency in preventing BPAR, and its fewer adverse events during the first 3 months post-transplantation. It is important to underline that the use of everolimus in de novo renal transplant recipients was not associated with more DGF, proteinuria, BPAR, NODAT, or surgical complications. However, our study had some weaknesses, being the first one to have a retrospective design. Furthermore, when considering the tacrolimus exposure between groups, the differences in renal function did not achieve statistical significance. In fact, tacrolimus trough levels were statistically comparable in the first 2 months post-transplantation and generally higher than the proposed target levels. Contrary to an important and bigger study [25] using a sirolimuscyclosporine combination in which cyclosporine dose was reduced by 80%, we decided for a modest 25% reduction of the tacrolimus dose (0.15 mg/kg/day) in our study group that
may have been insufficient to achieve a clear-cut difference on tacrolimus exposure between groups. We also believe that during the follow-up, the nephrologists’ reluctance in properly decreasing tacrolimus exposure probably contributed to a smaller reduction in its serum levels and might have been the main reason for these results. This may be a reflection of our nephrologists’ inexperience with the everolimus-tacrolimus combination, and this very issue has already been described [23]. Moreover we underline that we used the prolonged formulation of tacrolimus (Advagraf) ab initio, which is associated with a tendency on initial lower tacrolimus concentration when comparing to the twice-daily formulation (Prograf). Bearing all this in mind, the authors chose to reduce (only) slightly the tacrolimus dose in the study group, as otherwise there were concerns regarding a higher risk of acute rejection in the immediate posttransplantation period. Finally, we would like to stress that if target trough levels had been achieved with a significant difference in tacrolimus exposures and the group’s
Table 4. Tacrolimus and Everolimus Trough Levels in the First 3 Months Post-transplantation
Month 1 Tacrolimus, Everolimus, Month 2 Tacrolimus, Everolimus, Month 3 Tacrolimus, Everolimus,
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value
median ng/mL (minemax) median ng/mL (minemax)
10.8 (4.8e22.0) d
8.7 (4.3d18.0) 5.0 (2.8e6.8)
.101* d
median ng/mL (minemax) median ng/mL (minemax)
9.3 (5.1e13.8) d
9.1 (3.1e13.4) 4.7 (2.5e7.2)
.775* d
median ng/mL (minemax) median ng/mL (minemax)
8.7 (5.1e12.9) d
7.7 (4.9e10.8) 4.4 (3.0e7.1)
.034† d
*Mann-Whitney test. † Student t test.
910
SANTOS, SANTOS, MACÁRIO ET AL Table 5. Adverse Events Related to Immunosuppressive Protocols
NODAT incidence, n (%) Surgical complications Lymphocele, n (%) Surgical wound dehiscence, n (%) Urinary leaks, n (%)
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value*
6 (17.6)
4 (15.4)
1.000
1 (2.9) 0 (0.0) 2 (5.9)
0 (0.0) 2 (7.7) 0 (0.0)
1.000 .184 .501
*c2 test.
dimensions were increased, it is our belief that there would be a statistically relevant difference in renal function between both groups. Another important aspect to discuss is the proteinuria assessment. Despite not having the same accuracy as a 24hour sample, a urine spot sample (mg/dL) in each appointment was a simple method to monitor proteinuria and whenever there was a progressive increase in its levels, it warned the nephrologist of the need to use more accurate methods, particularly regarding recipients with ESRD secondary to glomerular diseases. Obviously a longer follow-up would allow a better proteinuria assessment. Moreover, it cannot be overlooked that the 2 cases of BPAR in the control group developed after an infectious insult and were histologically mild. We are also aware that the population studied had a relatively low risk of allograft rejection and that the tendencies and results shown in this retrospective analysis may not be completely applied to immunologically higher risk recipients. In conclusion, in the first 3 months post-transplantation the combined therapy of everolimus and low-dose tacrolimus was as effective and safe as standard dose tacrolimus protocols in de novo renal transplant recipients. A longer follow-up study with a larger cohort of recipients is required for more accurate results and is now under way. REFERENCES [1] Meier-Kriesche HU, Schold JD, Srinivas TR, Kaplan B. Lack of improvement in renal allograft survival despite a marked decrease in acute rejection rates over the most recent era. Am J Transplant 2004;4:378e83. [2] Zeier M, Döhler B, Opelz G, Ritz E. The effect of donor gender on graft survival. J Am Soc Nephrol 2002;13:2570e6. [3] Chapman JR, Valantine H, Albanell J, et al. Proliferation signal inhibitors in transplantation: questions at the cutting edge of everolimus therapy. Transplant Proc 2007;39:2937e50. [4] Langer RM, Hene R, Vitko S, et al. Everolimus plus early tacrolimus minimization: a phase III, randomized, open-label, multicentre trial in renal transplantation. Transpl Int 2012;25:592e602. [5] Chapman JR, O’Connell PJ, Nankivell BJ. Chronic renal allograft dysfunction. J Am Soc Nephrol 2005;16:3015e26. [6] Pascual J, Marcen R, Ortuno J. Renal function: defining long-term success. Nephrol Dial Transplant 2004;19(Suppl 6):vi3e7.
[7] Nankivell BJ, Borrows RJ, Fung CL, O’Connell PJ, Allen RD, Chapman JR. The natural history of chronic allograft nephropathy. N Engl J Med 2003;349:2326e33. [8] Nankivell BJ, Chapman JR. Chronic allograft nephropathy: current concepts and future directions. Transplantation 2006;81: 643e54. [9] Jevnikar AM, Mannon RB. Late kidney allograft loss: what we know about it, and what we can do about it. Clin J Am Soc Nephrol 2008;3(Suppl 2):S56e67. [10] Veroux M, Corona D, Giuffrida G, et al. New-onset diabetes mellitus after kidney transplantation: the role of immunosuppression. Transplant Proc 2008;40:1885e7. [11] Ekberg H, Tedesco-Silva H, Demirbas A, et al. Reduced exposure to calcineurin inhibitors in renal transplantation. N Engl J Med 2007;357:2562e75. [12] Frimat L, Cassuto-Viguier E, Charpentier B, et al. Impact of cyclosporine reduction with MMF: a randomized trial in chronic allograft dysfunction. The ‘reference’ study. Am J Transplant 2006;6:2725e34. [13] Baboolal K. A phase III prospective, randomized study to evaluate concentration-controlled sirolimus (rapamune) with cyclosporine dose minimization or elimination at six months in de novo renal allograft recipients. Transplantation 2003;75:1404e8. [14] Mota A, Arias M, Taskinen EI, et al. Sirolimus-based therapy following early cyclosporine withdrawal provides significantly improved renal histology and function at 3 years. Am J Transplant 2004;4:953e61. [15] Gonwa TA, Hricik DE, Brinker K, Grinyo JM, Schena FP. Improved renal function in sirolimus-treated renal transplant patients after early cyclosporine elimination. Transplantation 2002;74: 1560e7. [16] Oberbauer R, Segoloni G, Campistol JM, et al. Early cyclosporine withdrawal from a sirolimus-based regimen results in better renal allograft survival and renal function at 48 months after transplantation. Transpl Int 2005;18:22e8. [17] Pascual J. Everolimus in clinical practiceerenal transplantation. Nephrol Dial Transplant 2006;21(Suppl 3):iii18e23. [18] Pascual J, Boletis IN, Campistol JM. Everolimus (Certican) in renal transplantation: a review of clinical trial data, current usage, and future directions. Transplantation Reviews 2006;20:1e18. [19] Vitko S, Margreiter R, Weimar W, et al. Everolimus (Certican) 12-month safety and efficacy versus mycophenolate mofetil in de novo renal transplant recipients. Transplantation 2004;78: 1532e40. [20] Pascual J. The use of everolimus in renal-transplant patients. Int J Nephrol Renovasc Dis 2009;2:9e21. [21] Vincenti F, Jensik SC, Filo RS, Miller J, Pirsch J. A longterm comparison of tacrolimus (FK506) and cyclosporine in kidney transplantation: evidence for improved allograft survival at five years. Transplantation 2002;73:775e82. [22] Jurewicz WA. Tacrolimus versus cyclosporin immunosuppression: long-term outcome in renal transplantation. Nephrol Dial Transplant 2003;18(Suppl 1):i7e11. [23] Chan L, Greenstein S, Hardy MA, et al. Multicenter, randomized study of the use of everolimus with tacrolimus after renal transplantation demonstrates its effectiveness. Transplantation 2008;85:821e6. [24] Lutz J, Zou H, Liu S, Antus B, Heemann U. Apoptosis and treatment of chronic allograft nephropathy with everolimus. Transplantation 2003;76:508e15. [25] Pliszcynsky J, Kahan BD. Better actual 10-year renal transplant outcomes of 80% reduced cyclosporine exposure with sirolimus base therapy compared with full cyclosporine exposure without or with concomitant sirolimus treatment. Transplant Proc 2011;43:3657e68.
Nephrology Department, CHUC, Coimbra, Portugal; and bUrology and Kidney Transplantation Department, CHUC, Coimbra, Portugal
ABSTRACT Background. Calcineurin inhibitors (CNIs) are the cornerstones of immunosuppressive management in renal allograft recipients even though their nephrotoxicity may contribute to a reduced long-term graft survival. This has created a great interest in improving immunosuppressive strategies in the early post-transplantation period. Proliferation signal inhibitors (PSIs), such as everolimus, are promising alternatives, although their side effects may have a drawback in de novo renal transplant recipients, for instance, delaying renal function in the presence of renal ischemia/acute tubular necrosis and predisposing to lymphocele development. Study and Methods. A retrospective study was developed to compare the combined therapy of low-dose tacrolimus and everolimus (study group) with mycophenolate mofetil/ mycophenolic acid and standard-dose tacrolimus (control group) in the first 3 months posttransplantation. The study’s end-points concerned renal graft function, proteinuria, incidence of biopsy-proven acute rejection, surgical complication rates, and incidence of new-onset diabetes after renal transplantation. Results. There was no more delayed graft function in the study group and graft function distribution was similar between groups. Median serum creatinine and eGFR were comparable as well as proteinuria levels. Generally, adverse events were rare in both groups and there were no significant statistical differences between them in terms of biopsy-proven acute rejection, surgical complication, and new-onset diabetes after renal transplantation rates. Conclusion. Despite the slightly lower tendency for serum creatinine in the study group, renal allograft function wasn’t statistically different between groups. Moreover, there weren’t more metabolic or surgical complications in the study group. Everolimus may be a choice in tacrolimus-sparing strategies, but a larger study and a longer follow-up are still required.
O
VER the last several decades there have been significant improvements in immunosuppressive therapy regarding the acute rejection rates achieved in the first year post-transplantation. However, long-term renal allograft survival has only marginally improved and remains a challenge [1e3]. Chronic allograft nephropathy (CAN, histologically described as interstitial fibrosis and tubular atrophy) is the main cause of graft failure and multiple factors account for it (e.g. calcineurin inhibitor (CNI) nephrotoxicity, donor age, graft quality, and comorbidities) [3e8]. CNIs have been the cornerstones of the immunosuppressive management in renal allograft recipients because of 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.03.042
906
their efficacy in preventing acute rejections. However, they are pleomorphic nephrotoxins and their long-term use contributes to the development of CAN and therefore compromising outcomes [5,7e9]. In addition, patients receiving CNIs have an increased risk of developing cardiovascular events and new-onset diabetes after transplantation (NODAT) [8e10]. Consequently, there has been strong *Address correspondence to Tânia Santos, Nephrology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-075 Coimbra, Portugal. E-mail: [email protected] ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 906e910 (2015)
EVEROLIMUS + LOW-DOSE TACROLIMUS THERAPY
907
Fig 1. Immunosuppressive protocols.
interest in developing new immunosuppressive regimens that improve long-term renal allograft survival rate while preserving renal function and without compromising immunosuppressive efficacy. Cyclosporine-sparing strategies using mycophenolate mofetil/mycophenolic acid or proliferation signal inhibitors (PSIs, also known as mammalian target of rapamycin inhibitors [mTORi]), such as sirolimus and everolimus, have demonstrated promising results [11e20]. Moreover, some studies [6,21,22] have pointed to the superiority of tacrolimus-based regimens when compared to cyclosporine-based ones, making tacrolimus the preferred CNI used in today’s clinical practice. Similarly, there has been growing interest in tacrolimus-sparing strategies, particularly those with everolimus [4,23]. Antiproliferative properties of everolimus may inhibit the underlying key mechanisms leading to CAN and ultimately improve longterm graft outcomes [24]. However, everolimus is associated with class specific adverse effects that may represent a drawback when considering them in de novo renal transplantation, such as delaying renal function recovery in the presence of renal ischemia/acute tubular necrosis, impairing wound healing with or without dehiscence and lymphocele development [20]. MATERIALS AND METHODS Study Design and Population This study analyzed retrospectively de novo renal transplant recipients from deceased heart beating donors between July 2013 and March 2014 that underwent 2 different immunosuppressive regimens: (1) tacrolimus 0.20 mg/kg/day plus acid mycophenolic/
mycophenolate mophetil plus prednisone (designated as control group) and (2) tacrolimus 0.15 mg/kg/day plus everolimus plus prednisone (designated as study group). All patients received a monoclonal antibody at day 0 and day 4 post-transplantation. A schematic illustration of the immunosuppressive protocols and immunosuppressor doses is provided in Fig 1. Patients submitted to living donor transplantation and those who received polyclonal antibodies were excluded. There was a 3-month follow-up period. In the study group the target trough levels for everolimus were 3e8 ng/ mL and for tacrolimus in the first month were 4e7 ng/mL and thereafter were 2e5 ng/mL. Tacrolimus target trough levels in the control group were 8e11 ng/mL. The aim of this study was to compare both groups in terms of (1) renal allograft function at discharge and the first, second, and third months post-transplantation; (2) incidence of biopsy-proven acute rejection (BPAR); (3) proteinuria levels at the first, second, and third months post-transplantation; (4) incidence of NODAT; and (5) incidence of surgical complications, such as lymphocele development (confirmed by ultrasonography and biochemical study), urinary leaks, and surgical wound dehiscence.
Statistical Methods Statistical analysis was made with SPSS Statistics version 22 (IBM, Chicago, Ill.,United States). Demographic and background characteristics used frequency (percentages) for qualitative variables and descriptive statistics with mean, standard deviation, median, minimum, and maximum for quantitative variables. The difference between groups was analyzed in terms of statistical significance. For quantitative variables with normal behavior, the Student t test was used, assuming equality of variances for a significance level > .05. For those without normal behavior, a Mann-Whitney test was performed. For qualitative nominal variables, c2 tests were applied.
908
SANTOS, SANTOS, MACÁRIO ET AL Table 1. Patient and Donor Demographics and Transplant Background Characteristics Control Group (n ¼ 34)
Variables
Patient demographics Age, mean years (SD) Male, n (%) Caucasian, n (%) Etiology of ESRD, n (%) Glomerulonephritis Hypertension/nephrosclerosis Polycystic renal disease Diabetes mellitus Unknown Number of HLA matches, n (%) Total (HLA 1) HLA-DR 1 PRA (most recent assessment), median % (minemax) Recipient CMV serologic status: CMV positive, n (%) Cold-ischemia time, mean hh:mm (SD) Donor demographics Age, median years (minemax) Age 60 years, n (%) Male, n (%) Cause of death Medical Traumatic
49.4 (12.7) 24 (70.6) 32 (94.1) 8 5 5 3 9 29 18 0.0 31 18:42
(23.5) (14.7) (14.7) (8.8) (26.5) (85.3) (52.9) (0.0e19.0) (91.1) (05:05)
Study Group (n ¼ 26)
P Value
48.2 (11.7) 15 (57.7) 26 (100.0)
.698* .299† .501† .382†
1 4 7 2 8 25 20 0.0 22 17:47
(3.8) (15.4) (26.9) (7.7) (30.8) (96.2) (76.9) (0.0e8.0) (85.6) (05:23)
53.0 (18e66) 8 (23.5) 12 (35.3)
53.0 (18e73) 5 (15.4) 17 (65.4)
22 (64.7) 12 (35.3)
16 (61.5) 10 (38.5)
.221† .056† .341‡ .454† .307‡ .638* .689† .021† .801†
Abbreviations: SD, standard deviation; ESRD, end-stage renal disease; HLA, human leucocyte antigen; CMV, cytomegalovirus; PRA, panel reactive antibody. *Student t test. † 2 c test. ‡ Mann-Whitney test.
RESULTS Patient and Donor Demographics
In total, 60 renal allograft recipients were analyzed: 34 were included in the control group and 26 in the study group. Patient and donor demographics and transplantation background characteristics were similar between groups (Table 1). Renal Function, Proteinuria, and BPAR Results
Immediate graft function (IGF) was seen in the majority of patients in both groups (Table 2). There was no more delayed graft function (DGF) in the study group. Instead, graft function distribution in terms of IGF, SGF, and DGF was similar between groups (P ¼ .426). Additionally, despite not having statistical significance, there was a propensity for a slightly better renal allograft function in the study group throughout the first 3 months post-transplantation as measured by serum creatinine and eGFR (MDRD) (Table 3). Proteinuria levels were comparable between groups (P ¼ .445, .780, and .383 at month 1, 2, and 3, respectively) with a Table 2. Renal Allograft Function Graft Function
IGF, n (%) SGF, n (%) DGF, n (%)
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value*
18 (52.9) 7 (20.6) 9 (26.5)
18 (69.2) 4 (15.4) 4 (15.4)
.426
Abbreviations: IGF, immediate graft function; SGF, slow graft function; DGF, delayed graft function. *c2 test.
constant median of 5 mg/dL. Despite having higher incidence of BPAR in the control group, the difference was not statistically significant (Table 3). Both cases occurred in the first 2 weeks post-transplantation in patients with concurrent nosocomial infections. Histologically they were classified as borderline AR (Banff, 2013) and favorably treated with corticosteroid pulses with a corresponding decline of serum creatinine. Tacrolimus and Everolimus Serum Trough Levels
On the third month tacrolimus trough level variation between groups achieved statistical significance, being lower in the study group, although not as low as we expected. Immunosuppressive trough levels during the follow-up period are detailed in Table 4. Adverse Events: Surgical Complications and NODAT Incidence
Globally, the incidence of adverse events was very low in both groups, with surgical complications being rare. Meanwhile the NODAT prevalence was 17.6% and 15.4% in the control and study group, respectively (Table 5). No patients died or lost their renal graft in the first 3 months post-transplantation. DISCUSSION
In Portugal, our center was the first to use an everolimusbased tacrolimus-sparing strategy. A retrospective analysis
EVEROLIMUS + LOW-DOSE TACROLIMUS THERAPY
909
Table 3. Evolution of Renal Allograft Function, Proteinuria, and BPAR Incidence in the First 3 Months Post-transplantation
Renal allograft function and proteinuria results Discharge SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Month 1 SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Proteinuria, median mg/dL (minemax) Month 2 SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Proteinuria, median mg/dL (minemax) Month 3 SCr, median mg/dL (minemax) eGFR (MDRD), median mL/min/1.73 m2 (minemax) Proteinuria, median mg/dL (minemax) Acute rejection incidence, n (%)
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value
1.54 (0.75e2.98) 48.0 (19.0e107.0)
1.24 (0.63e4.09) 56.5 (11.0e102.0)
.123* .266*
1.37 (0.82e3.54) 50.0 (18.0e100.0) 5.0 (0.0e70.0)
1.29 (0.71e3.04) 62.5 (22.0e105.0) 5.0 (0.0e70.0)
.175* .156* .445*
1.34 (0.73e2.21) 54.5 (34.0e109.0) 5.0 (0.0e30.0)
1.23 (0.71e2.95) 58.0 (16.0e93.0) 5.0 (0.0e50.0)
.660* .748† .780*
1.31 55.0 5.0 2
1.18 57.0 5.0 0
.620† .697† .383* .501
(0.79e2.16) (36.0e96.0) (0.0e50.0) (5.9)
(0.71e2.13) (30.0e106.0) (0.0e70.0) (0.0)
Abbreviations: SCr, serum creatinine; SD, standard deviation; eGFR, estimated glomerular filtration rate; MDRD, modification of diet in renal disease 4-variable formula. *Mann-Whitney test. † Student t test.
was made, and the data collected from that experience allowed us to corroborate that this strategy has achieved good results in terms of renal function, its efficiency in preventing BPAR, and its fewer adverse events during the first 3 months post-transplantation. It is important to underline that the use of everolimus in de novo renal transplant recipients was not associated with more DGF, proteinuria, BPAR, NODAT, or surgical complications. However, our study had some weaknesses, being the first one to have a retrospective design. Furthermore, when considering the tacrolimus exposure between groups, the differences in renal function did not achieve statistical significance. In fact, tacrolimus trough levels were statistically comparable in the first 2 months post-transplantation and generally higher than the proposed target levels. Contrary to an important and bigger study [25] using a sirolimuscyclosporine combination in which cyclosporine dose was reduced by 80%, we decided for a modest 25% reduction of the tacrolimus dose (0.15 mg/kg/day) in our study group that
may have been insufficient to achieve a clear-cut difference on tacrolimus exposure between groups. We also believe that during the follow-up, the nephrologists’ reluctance in properly decreasing tacrolimus exposure probably contributed to a smaller reduction in its serum levels and might have been the main reason for these results. This may be a reflection of our nephrologists’ inexperience with the everolimus-tacrolimus combination, and this very issue has already been described [23]. Moreover we underline that we used the prolonged formulation of tacrolimus (Advagraf) ab initio, which is associated with a tendency on initial lower tacrolimus concentration when comparing to the twice-daily formulation (Prograf). Bearing all this in mind, the authors chose to reduce (only) slightly the tacrolimus dose in the study group, as otherwise there were concerns regarding a higher risk of acute rejection in the immediate posttransplantation period. Finally, we would like to stress that if target trough levels had been achieved with a significant difference in tacrolimus exposures and the group’s
Table 4. Tacrolimus and Everolimus Trough Levels in the First 3 Months Post-transplantation
Month 1 Tacrolimus, Everolimus, Month 2 Tacrolimus, Everolimus, Month 3 Tacrolimus, Everolimus,
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value
median ng/mL (minemax) median ng/mL (minemax)
10.8 (4.8e22.0) d
8.7 (4.3d18.0) 5.0 (2.8e6.8)
.101* d
median ng/mL (minemax) median ng/mL (minemax)
9.3 (5.1e13.8) d
9.1 (3.1e13.4) 4.7 (2.5e7.2)
.775* d
median ng/mL (minemax) median ng/mL (minemax)
8.7 (5.1e12.9) d
7.7 (4.9e10.8) 4.4 (3.0e7.1)
.034† d
*Mann-Whitney test. † Student t test.
910
SANTOS, SANTOS, MACÁRIO ET AL Table 5. Adverse Events Related to Immunosuppressive Protocols
NODAT incidence, n (%) Surgical complications Lymphocele, n (%) Surgical wound dehiscence, n (%) Urinary leaks, n (%)
Control Group (n ¼ 34)
Study Group (n ¼ 26)
P Value*
6 (17.6)
4 (15.4)
1.000
1 (2.9) 0 (0.0) 2 (5.9)
0 (0.0) 2 (7.7) 0 (0.0)
1.000 .184 .501
*c2 test.
dimensions were increased, it is our belief that there would be a statistically relevant difference in renal function between both groups. Another important aspect to discuss is the proteinuria assessment. Despite not having the same accuracy as a 24hour sample, a urine spot sample (mg/dL) in each appointment was a simple method to monitor proteinuria and whenever there was a progressive increase in its levels, it warned the nephrologist of the need to use more accurate methods, particularly regarding recipients with ESRD secondary to glomerular diseases. Obviously a longer follow-up would allow a better proteinuria assessment. Moreover, it cannot be overlooked that the 2 cases of BPAR in the control group developed after an infectious insult and were histologically mild. We are also aware that the population studied had a relatively low risk of allograft rejection and that the tendencies and results shown in this retrospective analysis may not be completely applied to immunologically higher risk recipients. In conclusion, in the first 3 months post-transplantation the combined therapy of everolimus and low-dose tacrolimus was as effective and safe as standard dose tacrolimus protocols in de novo renal transplant recipients. A longer follow-up study with a larger cohort of recipients is required for more accurate results and is now under way. REFERENCES [1] Meier-Kriesche HU, Schold JD, Srinivas TR, Kaplan B. Lack of improvement in renal allograft survival despite a marked decrease in acute rejection rates over the most recent era. Am J Transplant 2004;4:378e83. [2] Zeier M, Döhler B, Opelz G, Ritz E. The effect of donor gender on graft survival. J Am Soc Nephrol 2002;13:2570e6. [3] Chapman JR, Valantine H, Albanell J, et al. Proliferation signal inhibitors in transplantation: questions at the cutting edge of everolimus therapy. Transplant Proc 2007;39:2937e50. [4] Langer RM, Hene R, Vitko S, et al. Everolimus plus early tacrolimus minimization: a phase III, randomized, open-label, multicentre trial in renal transplantation. Transpl Int 2012;25:592e602. [5] Chapman JR, O’Connell PJ, Nankivell BJ. Chronic renal allograft dysfunction. J Am Soc Nephrol 2005;16:3015e26. [6] Pascual J, Marcen R, Ortuno J. Renal function: defining long-term success. Nephrol Dial Transplant 2004;19(Suppl 6):vi3e7.
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