Purpose: The adverse effect of tacrolimus on renal function is well documented and lower goal levels are presumed to lead to superior renal outcomes. However the optimal tacrolimus goal for preservation of renal function has not been established.

Methods: All patients receiving cardiac transplant at a single institution from 1/02 until 9/11. The goal tacrolimus level (ng/mL) were as follows: no induction 12-15, thymoglobulin induction 10-12, alemtuzumab induction 8-10.

Results: A total of 393 patients were included, 123 (31%) no induction, 211 (54%) alemtuzumab, and 59 (15%) thymoglobulin. Baseline characteristics were not different for groups: mean age 55 years, 75% male, 88% white, 53% ischemic, VAD 29%, CMV mismatch 20%. Donor characteristics were not different: mean age 35 years, male 65%, 78% white. Ischemic time was shorter for alemtuzumab 192 v. 173 v. 202 minutes, p = 0.0001 for no-induction, almetuzumab, and thymoglobulin. Maintenance was not different for groups: 99% TAC, 99%MMF. Five year freedom from significant rejection was 45% v. 75% v. 80%, p<0.0001 for no induction, alemtuzumab, and thymoglobulin. Goal tacrolimus levels were significantly higher and in target range for the first 2 years post-transplant, despite this there was no significant difference in renal function over the first 2 years. In years 4 and 5 achieved tacrolimus levels were 8-10 despite original goals, but the no induction group had superior renal function.

Conclusions: Although patients who did not receive induction had higher CrCl pretransplant, there were no differences in renal function through the first two post-transplant years, despite higher goal and achieved levels and a higher incidence of rejection without induction. Non-induced controls had significantly better CrCl from years 4-5 with similar achieved tacrolimus levels.

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