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Role of PSI in Renal Transplantation
Indian J Transplant 2008; 2: 32-50
infections. All patients were treated with oral fluconazole and topical therapy. Duration of therapy < 3 weeks and presence of diabetes were predictor of relapse. 6 patients had subcutaneous infection. 4 patients had phaeohyphomycosis. Other causes were aspergillus (1) and Cryptococcus(1). 3 patients needed surgery. 2 patients needed repeated course of amphotericin B.
Conclusions : Duration of treatment < 3 weeks and diabetes were predictor of relapse. Patients with subcutaneous infection may need surgical excision.
Role of PSI in Renal Transplantation
Vijay Kher, Sanjeev Gulati, Dinesh Khullar, Sandeep Guleria, Vivekanand Jha, PP Verma, RK Sharma For the North Zone PSI Consensus Group
Introduction : Chronic allograft dysfunction continues to be a significant problem in renal allograft recipients despite the introduction of newer immunosuppression agents
Methods: A consensus meeting of nephrologists and transplant surgeons from North :Zone was organized to review the role of PSIs in renal transplantation. A modiTted Delphi process was used to evaluate the following:1) to identify patients who would benefit for use of PSIs 2) evaluate the status of PSI in maintenance setting 3) to define methods used to diagnose renal function deterioration. Three of the members were asked to review the available literature and present it before the group. This was followed by a discussion and inputs from the each of the participating members. The conclusions were based on the degree of consensus achieved.
Results : The group felt that PSis are a useful addition to the immunosuppressive armamentarium. It was agreed that PSI would be beneficial in special clinical situations like patients with pre-existing history of malignancies in post transplant period or those who are at high risk of developing malignancies such as those who had received long term immunosuppression for the native kidney disease. Another special scenario where PSIs are likely to be beneficial are in patients who have developed post transplant hemolytic uremic syndrome due to cyclosporine / tacrolimus. In maintenance immunosuppression it was felt that PSIs could be effective if introduced at the right time. Based on current evidence, it was felt that they should be avoided as denovo therapy and the introduction delayed upto 4 weeks.
Abstrcats: XVIII Conference of ISOT 2007
35
The optimal time of introduction is still unknown but could be between 1-3 months. In the maintenance setting, it was felt that even the low dose CNI combination with PSI is nephrotoxic and it may be preferable to withhold CNls and combine PSis with MMF. TDM is mandatory in these patients. Further it was agreed that protocol biopsy would be the optimal method to identify early allograft dysfunction.
Conclusion : The group concluded that PSIs are a useful addition to the current immunosuppressive armamentarium. The cost of immunosuppression remains an important deciding factor in our country. Further studies with specific protocols are required in Indian settings.
High rate of Acute Rejections in Renal Transplant Recipients with Neoral & Mycophenolate in the MOST Study - The Indian Experience A Dosing Consideration V Kher, V. Sakhuja, RK Sharma, HS Kohli, S Sundar, GT John, M Rajapurkar, HS Ballal, CM Thiagarajan, B Subharao For the MOST Study Group - India
The multinational observational study in transplantation (MOST) was under taken with the objective of documenting immunosuppressive treatment optiOFIS and the clinical outcomes of their use under conditions of normal clinical practice in large population of transplant recipients. 1204 patients (964 denovo and 195 on maintenance therapy) at nine renal transplant centers were enrolled throughout India; to study the impact of different immunosuppressive regimens use in combination with Neoral. Globally 20243 patients (14993 evaluatble patients) (GLOBAL MOST Group) were available for comparison. All patients received Neoral based therapy (55 % Neoral + Azathioprine + Steroid; 33 % Neoral + MMF + Steroid). Mean follow up was 19 + 6 + 13. 9 months, The incidence of AR, BPAR and BPCR were 18, 10 & < 10% respectively. Patients receiving Neoral based MMF therapy showed significantly higher AR (27% vs 12 %) and more so at 4th & 5th year, quite in contrast to the global data, Between 1 - 5 years mean dose of Neoral was 1. 5 to 2. 5 mg/kg and MMF 750 mg to 1. 2 gms/day amongst Indian patients in contrast to 2. 5- 3 mg/kg of Neoral & 1. 5 to 1. 8 gms/day of MMF in the global data. This is largest multicentric data in India showing that low dose of MMF with Neoral leads to higher rates of acute rejections especially late acute rejections.
Copyright © 2008 by The Indian Society of Organ Transplantation
infections. All patients were treated with oral fluconazole and topical therapy. Duration of therapy < 3 weeks and presence of diabetes were predictor of relapse. 6 patients had subcutaneous infection. 4 patients had phaeohyphomycosis. Other causes were aspergillus (1) and Cryptococcus(1). 3 patients needed surgery. 2 patients needed repeated course of amphotericin B.
Conclusions : Duration of treatment < 3 weeks and diabetes were predictor of relapse. Patients with subcutaneous infection may need surgical excision.
Role of PSI in Renal Transplantation
Vijay Kher, Sanjeev Gulati, Dinesh Khullar, Sandeep Guleria, Vivekanand Jha, PP Verma, RK Sharma For the North Zone PSI Consensus Group
Introduction : Chronic allograft dysfunction continues to be a significant problem in renal allograft recipients despite the introduction of newer immunosuppression agents
Methods: A consensus meeting of nephrologists and transplant surgeons from North :Zone was organized to review the role of PSIs in renal transplantation. A modiTted Delphi process was used to evaluate the following:1) to identify patients who would benefit for use of PSIs 2) evaluate the status of PSI in maintenance setting 3) to define methods used to diagnose renal function deterioration. Three of the members were asked to review the available literature and present it before the group. This was followed by a discussion and inputs from the each of the participating members. The conclusions were based on the degree of consensus achieved.
Results : The group felt that PSis are a useful addition to the immunosuppressive armamentarium. It was agreed that PSI would be beneficial in special clinical situations like patients with pre-existing history of malignancies in post transplant period or those who are at high risk of developing malignancies such as those who had received long term immunosuppression for the native kidney disease. Another special scenario where PSIs are likely to be beneficial are in patients who have developed post transplant hemolytic uremic syndrome due to cyclosporine / tacrolimus. In maintenance immunosuppression it was felt that PSIs could be effective if introduced at the right time. Based on current evidence, it was felt that they should be avoided as denovo therapy and the introduction delayed upto 4 weeks.
Abstrcats: XVIII Conference of ISOT 2007
35
The optimal time of introduction is still unknown but could be between 1-3 months. In the maintenance setting, it was felt that even the low dose CNI combination with PSI is nephrotoxic and it may be preferable to withhold CNls and combine PSis with MMF. TDM is mandatory in these patients. Further it was agreed that protocol biopsy would be the optimal method to identify early allograft dysfunction.
Conclusion : The group concluded that PSIs are a useful addition to the current immunosuppressive armamentarium. The cost of immunosuppression remains an important deciding factor in our country. Further studies with specific protocols are required in Indian settings.
High rate of Acute Rejections in Renal Transplant Recipients with Neoral & Mycophenolate in the MOST Study - The Indian Experience A Dosing Consideration V Kher, V. Sakhuja, RK Sharma, HS Kohli, S Sundar, GT John, M Rajapurkar, HS Ballal, CM Thiagarajan, B Subharao For the MOST Study Group - India
The multinational observational study in transplantation (MOST) was under taken with the objective of documenting immunosuppressive treatment optiOFIS and the clinical outcomes of their use under conditions of normal clinical practice in large population of transplant recipients. 1204 patients (964 denovo and 195 on maintenance therapy) at nine renal transplant centers were enrolled throughout India; to study the impact of different immunosuppressive regimens use in combination with Neoral. Globally 20243 patients (14993 evaluatble patients) (GLOBAL MOST Group) were available for comparison. All patients received Neoral based therapy (55 % Neoral + Azathioprine + Steroid; 33 % Neoral + MMF + Steroid). Mean follow up was 19 + 6 + 13. 9 months, The incidence of AR, BPAR and BPCR were 18, 10 & < 10% respectively. Patients receiving Neoral based MMF therapy showed significantly higher AR (27% vs 12 %) and more so at 4th & 5th year, quite in contrast to the global data, Between 1 - 5 years mean dose of Neoral was 1. 5 to 2. 5 mg/kg and MMF 750 mg to 1. 2 gms/day amongst Indian patients in contrast to 2. 5- 3 mg/kg of Neoral & 1. 5 to 1. 8 gms/day of MMF in the global data. This is largest multicentric data in India showing that low dose of MMF with Neoral leads to higher rates of acute rejections especially late acute rejections.
Copyright © 2008 by The Indian Society of Organ Transplantation