The effect of later change or modulation of immunosuppression on long-term renal transplant results

Proper maintenance of immunosuppression is required to achieve long-term graft survival. The aim of this study was to evaluate the effect of change or modulation of an immunosuppressive regimen (IR) on graft survival during the posttransplant period in patients undergoing kidney transplantation. A total of 1164 patients who underwent kidney transplantation between January 1997 and December 2008 at Yonsei University Health System were enrolled. All patients initially received calcineurin inhibitor (CNI)-based double or triple IR (DIR and TIR, respectively). The causes of IR changes or modulation were reviewed retrospectively. Graft survival rate was compared according to types of maintenance immunosuppression (DIR versus TIR). Initially, DIR and TIR were adopted in 201 (17.3%) and 963 (82.7%) recipients, respectively. In 77 DIR recipients (38.8%) and 271 TIR recipients (28.1%), IRs were changed. Among recipients of an initial DIR, the most frequent reasons for IR change were acute rejection (50%) within 6 months of transplantation and chronic allograft dysfunction (70%) after 6 months. In TIR recipients, the reasons for IR change included drug toxicity or drug-related side effects (34.3%) within 6 months of transplantation and complications related to overimmunosuppression (39.3%) after 6 months. The group in which the IR was changed from the initial DIR to the later TIR had a statistically superior graft survival rate compared to the group that did not have a change in the initial DIR (P = .032). In contrast, TIR recipients without change had better graft survival rate than recipients with initial TIR change to later DIR (P < .001). Change or modulation of immunosuppression from initial DIR to later TIR could affect long-term graft survival.