Bootcongres

Introduction: In patients with type I diabetes mellitus and (or approaching) end-stage renal failure, simultaneous pancreas-kidney (SPK) transplantation restores renal function and cures diabetes with stabilization of secondary complications, including retinopathy and neuropathy. Induction therapy changed significantly from no induction (1987-1999), to intravenous anti-thymocyte globulin (ATG) or IL2-receptor blocker (IL2-RB) and, since 2007, steroid-free with Alemtuzumab 30 mg subcutaneously. This study evaluated acute rejection rate and time to rejection according to type of induction therapy. Methods: Between 1999 and 2012 a total of 208 SPK transplant recipients received either induction with ATG/ZPX iv. (n=132) or Alemtuzumab sc. (n=76). Maintenance therapy consisted of a calcineurin inhibitor, mycophenolate and steroids (in case of ATG/ZPX). Results: One-year patient survival was 95.4% (±1.8) and 97.2% (±2.0) in SPK patients with ATG/ZPX and Alemtuzumab, respectively (p=0.478). Kidney and pancreas graft survival at one-year was 97.7% (±1.3) vs. 98.4% (±1.6) and 89.4% (±2.7) vs. 98.7% (±1.3) for patients with ATG/ZPX and Alemtuzumab, respectively (with p-values of 0.640 and 0.015). The cumulative incidence of rejection at six months was 43.2% (±4.3) vs. 16.1% (±4.3) with ATG/ZPX or Alemtuzumab (p<0.0005). The median time to the first rejection episode was 17 days (14-23) in patients with ATG/ZPX induction and 112 days (23-137) with Alemtuzumab induction. Remarkably, in patients with Alemtuzumab induction a biphasic distribution was seen, with a first peak at a median of 19 days (9-23), and a second at a median of 123 days (112-141).

Conclusion: In SPK recipients, a steroid-free regime with Alemtuzumab induction significantly reduced acute rejection rates and resulted in better survival. Interestingly, within the Alemtuzumab group a second peak incidence in acute rejection was noted, attributable to an increase in effector T lymphocytes as reported in the literature.