Risk-stratification of renal transplant recipients based on immunologic risk factors allows for tailored immunosuppression (IS), but long term follow up is limited. This study evaluates the impact on clinical outcomes of a risk-stratified IS protocol in renal transplant recipients.

This is a retrospective single center cohort study of adult solitary renal transplants from 2011 to 2014 comparing the risk-stratified group (RS) to historic controls (HC). Risk-stratification was based on immunological risk (sensitization and age) with total dosing of mycophenolate mofetil (MMF) ranging from 1.5-2 g/day and rabbit antithymocyte globulin (ATG) ranging from 1.5-6 mg/kg to target absolute lymphocyte counts less than 100 cells/[micro]L. HC received 2g/day MMF and 4.5-6 mg/kg ATG for immediate/delayed graft function. Tacrolimus goal trough levels were identical in both groups. Three year patient and graft survival, 6 month and 3 year renal function, infection, and rejection rates were reported. Univariate and Kaplan-Meier analysis was performed and p<0.05 was consider significant.

169 patients underwent renal transplant, 55 in the HC and 114 in the RS group. Baseline demographics were similar including: age (RS: 51 ± 13 vs HC: 52± 13, p=NS), BMI (30 ± 5 vs 30 ± 5, p=NS), % male (62 vs 56%, p=NS), African American (31% vs 31%, p=NS), risk stratification (low risk: 52% vs 53%, p=NS, high risk 33 vs 37%, p=NS, elderly: 15% vs 11%, p=NS) and delayed graft function (25% vs 13%, p=NS). RS received lower ATG dosing per kg (4.3±1.3 vs 4.9 ± 1.6 mg/kg, p=0.01) and total dosage (333 ± 114 mg vs 455 ± 132 mg, p<0.005). There was no difference in 3 year patient (97% vs 93%,p=NS) and graft survival (92 vs 91%, p=NS). No significant differences were observed in mean eGFR at 6 months (57 vs 61 ml/min/m², p=NS). No significant differences in ACR were observed at 6 (12 vs 6%, p=NS), 12 (14 vs 13, p=NS) or 36 months (15 vs 16%, p=NS). No significant differences in AMR were observed at 6 (5 vs 6%, p=NS), 12 (8 vs 6%, p=NS) or 36 (9 vs 6%, p=NS) months. CMV viremia rates were comparable up to one year post transplant (19 vs 18%, p=NS). BK viremia rates were comparable at 6 (8 vs 18%, p=NS) and 12 months (12 vs 20%, p=NS).

ATG dosing based on individualized patient rejection risk maintains excellent clinical outcomes through 3 years follow up vs. historical control, while utilizing less induction IS; thereby, improving the value of care provided.

CITATION INFORMATION: Dann J., Agarwal A., Bradley M., Geyston J., Ally W. Individualized Immunosuppression through Risk-Stratification in Renal Transplantation Preserves Excellent Outcomes at Three Years Am J Transplant. 2017;17 (suppl 3).

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