*Purpose: Mycophenolic acid (MPA) exposure correlates inversely with the risk of acute rejection; however, evidence also suggests that systemic MPA exposure also determines the extent of gastrointestinal (GI) toxicity which is a known side effect of MPA. In an effort to decrease MPA-related GI toxicity, we changed our protocol in 2019 from discharging kidney transplant recipients on mycophenolate mofetil equivalents (MME) of 2000mg/day to 1500mg/day.

*Methods: A retrospective cohort study was performed of adult kidney transplant recipients transplanted between January 1, 2018 and July 1, 2020 and discharged on a MPA product. Multiorgan transplants and death during index hospitalization were excluded. Patients were classified based on MME discharge dose. Per protocol, patients received lymphocyte depleting induction, tacrolimus, +/- corticosteroids. The primary outcome was the incidence of AR. Secondary outcomes included 3-month hospital readmission rates and patient and allograft survival.

*Results: A total of 708 patients were included (264 in the MME 2000mg/day group and 444 in the MME 1500mg/day group). Baseline characteristics were similar between groups, with the majority being male, mean age ~50 years, and slight majority Caucasian (50-55%). More patients in the 2000mg/day group were on corticosteroids (54% vs 41%; p=0.001). Overall (79.5% vs 73.4%; p=0.066), as well as GI-related (9.8% vs 11.5%; p=0.498), 3-month hospital readmissions were not different between the 2000mg/day and the 1500mg/day groups, respectively. There was no difference in the time to (figure 1) or incidence (4.9% 2000mg/day vs 5.8% 1500mg/day; p= 0.599) of AR between groups. There was no difference in the rates of patient or allograft survival between groups.

*Conclusions: Reduced-dose MPA was safe and effective in a predominately steroid-free kidney transplant population.

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