TRANSPLANTATION WITHOUT MAINTENANCE CORTICOSTEROIDS IN 1-HAPLOTYPE AND 2-HAPLOTYPE MATCHED LIVING RELATED RENAL TRANSPLANT RECIPIENTS TREATED WITH MYCOPHENOLATE MOFETIL AND CYCLOSPORINE

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419 Approximately 20-30% of living related renal transplant (LRT) recipients experience significant steroid associated complications. Specific subgroups of LRT may be immunologically privileged to allow early steroid withdrawal or transplantation without maintenance corticosteroids. These groups include 2-Haplotype (2-HP) matched patients and 1-Haplotype (1-HP) recipients with a low or negative pretransplant mixed lymphocyte culture (MLC). The introduction of Mycophenolate Mofetil (MMF) as replacement for Azathioprine (AZA) in Cyclosporine (CSA) based immunosuppressive regimens has been associated with a significant reduction in the number and severity of rejection episodes in cadaveric transplant recipients. We report our experience utilizing double therapy of CSA/MMF from the initial posttransplant period without maintenance corticosteroids in 122-HP matched recipients and 141-HP matched patients with a low or negative pretransplant MLC. Respective control groups included 292-HP patients receiving double therapy of CSA/AZA without maintenance steroids and 151-HP matched LRT with a negative or low MLC initially treated with triple therapy of CSA/AZA and steroids who underwent steroid withdrawal 6 months posttransplant. MMF was dosed at 1 gm twice daily and AZA was provided at 1 mg/kg/day. All patients received an initial 3 day course of intravenous methylprednisolone (250 mg/day). There were no episodes of rejection or indications for addition of corticosteroids in the CSA/MMF treated 2-HP group (mean followup 11.4 ± 3.8 months) compared to 6/29 (21%) failure rate in the CSA/AZA group (mean followup 28 ± 12 months). Indications for addition of steroids in this group included: recurrent glomerulonephritis - 2 (33%), rejection - 3 (50%) and hemolytic uremic syndrome - 1 (17%). In the 1-HP low or negative MLC group receiving CSA/MMF, only 1/14 (7%) patients experienced a rejection episode requiring the addition of maintenance steroids compared to 3/15 (20%) 1-HP patients with a low or negative MLC undergoing late steroid withdrawal using CSA/AZA maintenance therapy. Combining both CSA/MMF groups together the overall success of steroid free immunosuppression was 25/26 (96%) compared to 35/44 (80%) in the CSA/AZA groups (p < 0.05). Renal function was similar in the CSA/MMF groups (serum creatinine 1.3 ± 0.2 mg/dl) compared to the CSA/AZA groups (1.4± 0.2 mg/dl, p-ns). There was no difference between groups in the WBC, Hgb or platelet counts. In conclusion, in addition to 2-HP matched recipients, 1-HP matched LRT recipients with a negative or low pretransplant MLC may undergo transplantation without the use of maintenance corticosteroids. This protocol obviates the need for a taper period and avoids all potential steroid related side effects. Although a high level of success may be achieved with a combination of CSA/AZA, replacement of AZA with MMF resulted in a significantly better opportunity to maintain a steroid free immunosuppressive regimen.

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