Tacrolimus (FK) has surpassed cyclosporine (CYA) as the calcineurin inhibitor (CNI) of choice for the vast majority of kidney transplant (KTX) programs. Yet, CYA continues to be an important alternative for patients intolerant to FK. The aim of this analysis was to assess the predominant causes of graft loss between patients receiving these two CNIs.

Methods:Retrospective study of 1,835 patients who received a KTX between 1999-2012. Patients were grouped based on initial CNI utilized: 1195 in tacrolimus (FK) group, 640 in cyclosporine (CYA) group. Data on baseline characteristics, clinical outcomes, and graft loss (Table 1) in both groups were analyzed.

Results:Cumulative acute rejection rates were 14% in the FK vs 24% in the CYA group. Despite relatively more marginal donor characteristics in the FK group, these patients had better graft survival rates compared to the CYA group. Three and five year graft survival rates were 88% and 84% respectively in the FK group compared to 79% and 70% respectively in the CYA group (P<0.001) (Figure 1). Patients in the FK group were more likely to have over-immunosuppression as a contribution to their graft loss, as manifested by a trend towards increased prevalence of infections and malignancies among these patients.

Conclusion:The use of FK-based maintenance immunosuppression therapy is associated with a significantly lower rate of acute rejection and better graft survival compared to CYA-based regimen. However, these data suggest that these improved outcomes are somewhat attenuated by inducing over-immunosuppression in a significant number of KTX recipients. Individualizing immunosuppression through risk-stratified CNI choice may lead to improved outcomes across all spectra of KTX patients.

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