The quadruple immunotherapy with low-dose cyclosporine achieved excellent kidney transplant outcome using non-heart beating donor grafts

OBJECTIVE: On the "marginal" donor, the non-heart beating donors (NHBD) often cause delayed graft function (DGF) and early graft loss. Despite the immunosuppressive ability of cyclosporine (CsA), grafts with prolonged warm ischemia (WI) tends to be affected by its nephrotoxicity. In that standpoint, the quadruple immunotherapy (QIT) with low-dose CsA was established and effects on the kidney Tx with NHBD graft was evaluated. Methods: From October 1990 until July 1996, 61 cadaveric kidney Txs were underwent using NHBD grafts with in situ cooling technique. WIT ranged from 1 to 52 minutes (mean 10.2). CsA was administered immediately after Tx at the initial dose of 4 mg/kg/day and the dose was adjusted according to the trough level as well as the graft function. Besides CsA, steroid, anti-lymphocyte globulin (ALG) and azathioprine (AZ), later converted to mizoribine (MZ), were employed as QIT. Results: Under QIT, 61 transplants were followed for 5 to 75 months post Tx. Fourteen grafts (23.0%) developed immediate function and 46 grafts (75.4%) showed DGF, ranged from 1 to 47 days (mean 12.7 days). One graft never progressed function due to a DIC kidney. The original extrarenal disease causesd two patient loss with functioning grafts at 1 and 14 months post Tx. Patient survival rates on 3 and 5 year were 96.3%, and 3 and 5 year graft survival rates were 94.7 and 86.5%, respectively, with current mean serum creatinine level at 1.8 mg/dl. Although acute rejection was noted in 26 cases, all grafts recovered function by steroid pulse with or without OKT-3 rescue therapy. Conclusions: Even with the high DGF rate, the quadruple immunotherapy, consisting of low-dose CsA, steroid, ALG and AZ (later to MZ), provide the excellent graft function using non-heart beating donor kidneys.