A multicenter experience with sequential ALG/cyclosporine therapy in renal transplantation

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Abstract
The influence of Class I and II HLA antigen matching on renal allograft survival in the cyclosporine era is controversial. The central question is whether current immunosuppressive protocols utilizing cyclosporine can safely and effectively suppress all degrees of in vivo alloreactivity. Data from six centers was collected. All centers utilize a “sequential” immunosuppressive protocol where ALG, azathioprine and prednisone are given for days 1 through 5 post‐transplant, followed by low‐dose cyclosporine and prednisone maintenance therapy. A total of 1217 cadaveric transplants were analyzed: 993 primary and 224 multiple. Patient follow‐up ranged from 4 months to 63 months. Overall graft survival of 993 primary cadaveric transplants was 87% at 1 year and 81% at 2 yr. Analysis of HLA A, B and Dr matching in these primary transplants demonstrated no significant advantage of well‐matched vs. poorly‐matched grafts. A, B matching alone, Dr matching alone, total A. B and Dr matching, or combinations of A, B and Dr match failed to demonstrate significant differences in 1 or 2 yr graft survival. There were 123 non‐transfused and 870 transfused primary grafts. No significantly improved graft survival was noted in the transfused group. Two cyclosporine protocols were analyzed, immediate cyclosporine without sequential therapy, 166 grafts, and delayed cyclosporine with “sequential” therapy, 827 grafts. Those primary transplants receiving sequential therapy with delayed cyclosporine had a significantly better 2‐yr graft function (84%) than those who received immediate cyclosporine therapy (74%). (p < .03). Age (>50 yr) did not influence outcome of primary transplantation. Overall primary graft survival at 2 yr was most influenced by immunosuppressive protocol. HLA A, B, Dr typing, transfusion, and age had little if any influence on outcome. Patients undergoing retransplantation followed a different pattern. Dr matching lead to a significantly better graft survival at 1 and 2 yr (p < .05). Patients > 50 yr proved to have significantly poorer graft survival (p < .01). Unlike primary cadaver grafts, immunosuppressive protocol did not influence outcome for re‐transplantation.