Benedetti

Butkus

C. Vivas

Gaston

H.A. Gritsch

J. McCauley

J.J. Fung

Kasiske

Koyama

Light

M.L. Jordan

McCauley

R. Shapiro

R.L. Simmons

T.E. Starzl

Tesi

V.P. Scantlebury

W. Irish

English

PubMed

Scantlebury, VP

Shapiro, R

Irish, W

Jordan, ML

Vivas, C

Gritsch, HA

Fung, JJ

McCauley, J

Simmons, RL

Starzl, TE

D-Scholarship@Pitt

Outcome of Kidney Transplantation in African-Americans Using Tacrolimus V.P. Scantlebury. R. Shapiro. W. Irish. M.L. Jordan. C. Vivas. H.A. Gritsch. J.J. Fung. J. McCauley. R.L. Simmons. and T.E. Starzl THE RESULTS of kidney transplantation in African-Americans have improved with oetter immunosup-pressive regimens. but the overall graft survival is reported by many to be inferior to that of non-Black recipients. 1- 3 The underlying impact of such factors as HLA matching. immunosuppressive regimes. socioeconomic status. or cen-ter effect has remained in question as many examine the underlying cause for the poorer graft survival.2.4 Our early experience with the use of tacrolimus has shown no difference in kidney allograft survival when compared to thc non-Black recipients.' We examine the outcome of the use of tacrolimus. a better immunosuppressive agent. to evaluate the effect of graft survival in African-American patients undergoing renal transplantation alone at the University of Pittsburgh. Minimum follow-up is 12 months. PATIENTS AND METHODS From October 1989 to December 1995. 1204 patients undelWent kidney transplants at the University of Pittsburgh. One hundred fifty four were performed in 148-African Americans (13%). Ex-cluded from the analysis were 16 patients who received a kidney in combination with bone marrow. liver. pancreas. or islet-cell trans-plantation. Of the remaining 138 transplants. 86 (62%) were treated with tacrolimus and steroids alone. Triple-therapy using azathioprine was the regimen in 31 (22%). cyclophosphamide in 16 (12%). and mycophenolate mofetil in 5 (4%). Adults made up 96% of patients with a mean age of 43 :': 13 years. One hundred four (76%) patients received their first trans-plant. while 32 patients undelWent retransplantation (25 second grafts. 6 third grafts. and 1 fourth graft.) The most common etiologies of renal failure were hypertension and diabetes. Panel reactive antibody level was 40 or less in 87% of the transplants. Cadaveric donors accounted for 92% of the transplants. RESULTS The 1- and 3-year actuarial patient survival was 96% and 92%. respectively (Fig 1). The 1- and 3-year actuarial graft survival was 86% and 70%. respectively. Twenry of 52 failed grafts were lost in the first year after transplantation. 11 as the result of nonfunction and/or rejection. Rejection was seen in 6R'.0 of the transplants. Twenty-five (1St;(,) required OKT3 for steroid-resistant rejection. Fif-teen of these went on to graft failure: six within the first vear © 1997 by ElseVier SCience Inc. 655 Avenue of the Americas. New York. NY 10010 Transplantation Proceedings. 29. 3731-3732 (1997) 80 ...... . '., " , ..... ' .. - Pallent survival (n=136) 20 • I • I Grafl survival (n=138) ". '. I •• , • I I •••••••• " l+-~~~K-~r-~r-~r-~r-~~-I~-I __ ~ Ole 18 24 30 .16 42 48 54 t>o Months After Transplantation Fig 1. African-American kidney transplantation under tacroli-mus: patient and graft survival. after transplantation. Loss of graft in all 15 cases was associated with infection and/or rejection. There were IS deaths: eight while on dialysis and 10 with a functioning graft. New onset diabetes was seen in 28 (25.7%) patients at risk, of whom 13 were able to discontinue insulin after lowering immunosuppression. Only 2% of the transplants were associated with a six HLA antigen-matched kidney. Eighty-four percent received a one to three antigen-matched graft. The mean creatinine at 1 and 3 years was 1.9 + 1.0 mgldL and 3.3 + 3.3 mgldL. respectively. The mean tacrolimus dose was 17 + 10 mgldL per day at I year and 13 + 7.0 mgldL per day at 3 years. DISCUSSION The overall graft survival for kidney transplantation has improved progressively, with better immunosuppressive regimens both for Black and non-Black recipients. Despite earlier reports of poorer kidney allograft survival in Afri-From the Thomas E. Starzl Transplantation Institute. Depart-ments of Surgery and Urology, University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania. USA. This work was supported by the National Institutes of Health. Bethesda. Maryland. Grant DK29961. Address reprint requests to Velma P. Scantlebury. MD. Thomas E. Starzl Transplantation Institute. 3705 Fifth Ave. 4A-470. Pitts-burgh, PA 15213. 0041-1345/97/$17.00 PII S0041-1345(97)01 090-7 3731 ;' I I I. i , 3732 can-Americans." 7 many others havc reported no racial differences in the outcome of renal transplantation. -.S How-ever. sueh reports have tended to have relatively short follow-up periods. In our analysis of ~ III African-Ameri-cans among the P1KO~l pnmary cadaveric kidncv reCipients in the 1991-1995 UNOS Scientitic Reglstrv Study." the I-year graft survival was essentially the same as the 23.280 "all other." Between I and 3 vears. however. the Afriean-Americans lost about 10% more grafts than the "all others" at every level of HLA match. Since beginning the use of tacrolimlls at the University of Pittsburgh in 1989. kidney transplant recipients have re-ceived tacrolimus as part of a randomized double or triple drug regimen. Induction antilymphocytic globulin has not been used routinely. Our results of patient and graft survival in this subgroup group of African-Americans arc equivalent to those found in an earlier smaller series reported by Shapiro et al 10 and are similar to those of others using quadruple therapy with OKT3 induction.ll.l; The fiscal and quality of life advantages of using tacrolimus without OKT3 are obvious. While many factors are responsible for the poorer out-come of African-Americans undergoing kidney transplan-tation, improved immunosuppression is more likely to play a significant role in the long-term than other proposed mechanisms. The challenge of improving the long-term SCANTLEBURY. SHAPIRO. IRISH ET AL graft sUl>wal in the African-American population will depend partly 'lll the abilitv to control rejection at noth the earlv and late stages after transplantatIOn. REFERENCES 1. Kasiske B. l'<cvlan J. Riggio R. et al: New Engl J Med 324:302. 19'11 2. Butkus D. Meydrech E. Raju S: New Engl J Mel! J27:840. 1992 3. Terasaki PI (cd): Clinical Transplants 1990. Los Angeles. Calif: UCLA Tissue Tvping Lahorator\': 1990. p 447 4. Gaston R: Blood Purification 14:327. 19'16 5. McCauley 1. Shapiro R. Woods H. et al: Transplant Proc 25:2468, 1993 6. Cecka 1M. Terasaki PI (cds): Clinical Transplants 1994. Los Angeles, Calif: UCLA Tissue Typing Lahoratory: 1994, p 1 7. Koyama H. Cecka J. Terasaki P: Transplantation 57:1064, 1'194 8. Light 1. Kelly 1. Aquino A. el al: Transplant Proc 25:2436, 1993 9. Scantlebury V. Gjertson D. Elizsaiw M. ct al: (in press) 10. Cecka 1M. Terasaki PI (eds): Clinical Transplants 1995. Los Angeles. Calif: UCLA Tissue Typing Laboratory: 1995. p 1'19 11. Benedetti E. Freels S. Coady N. et al: Am 1 Surg 172:56, 1996 12. Tesi R. Dehoisblanc M. Saul C. ct 31: Archives Surg 132:35, 1997 c 

Outcome of kidney transplantation in African-Americans using tacrolimus

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Outcome of kidney transplantation in African-Americans using tacrolimus

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