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When is the Optimal Time to Initiate the Renal-Sparing Protocol with Calcineurin Inhibitor Withdrawal?

N. Patel, M. Kittleson, J. Patel, T. Singer-Englar, S. Kim, D. Chang, B. Azarbal, A. Nikolova, L. Czer, F. Esmailian, J. A. Kobashigawa

Cedars-Sinai Smidt Heart Institute, Los Angeles, CA

Meeting: 2021 American Transplant Congress

Abstract number: 405

Keywords: Glomerular filtration rate (GFR), Renal function

Topic: Clinical Science » Heart » Heart and VADs: All Topics

Session Information

Session Name: Heart/LVAD: All Topics

Session Type: Poster Video Chat

Date: Saturday, June 5, 2021

Session Time: 7:30pm-8:30pm

 Presentation Time: 7:50pm-8:00pm

Location: Virtual

*Purpose: Renal dysfunction after heart transplantation (HTx) has been associated with higher morbidity and mortality. The most common cause of this renal dysfunction is the use of calcineurin inhibitors (CNIs). Many programs will utilize a renal sparing protocol (RSP) after 6-months post-transplant whereby the CNI is tapered off with the addition of a proliferation signal inhibitor added to the pre-existing mycophenolate mofetil. It is believed that weaning RSP earlier during renal dysfunction leads to better outcome. We sought to answer this question with review of our RSP experience.

*Methods: Between 1994-2017, we assessed 61 heart transplant patients with elevated creatinine. RSP was started at creatinine 1.5-2.0, 2.1-2.5, and 2.6-3.0 mg/dL. Renal function was measured by serum creatinine and glomerular filtration rate (GFR) at 6- and 12-months following initiation of RSP.

*Results: RSP initiated at the lowest elevation of serum creatinine resulted in a higher GFR compared to RSP at higher ranges. However, the overall improvement from baseline was similar (change in GFR around 9 cc/min., see table). The average time between transplant and initiation of RSP was 5.3 ± 4.2 years.

*Conclusions: RSP performed at earlier rising serum creatinine appears most beneficial in terms of restoring optimal kidney function.

Endpoints Creatinine 1.5-2.0 mg/dL (n=21) Creatinine 2.1-2.5 mg/dL (n=22) Creatinine 2.6-3.0 mg/dL (n=18) P-Value
Serum creatinine @ RSP initiation 1.80 ± 0.18 2.28 ± 0.13 2.75 ± 0.12 <0.001
Serum creatinine 6 months after RSP initiation 1.58 ± 0.39 1.85 ± 0.35 2.21 ± 0.52 <0.001
GFR @ RSP initiation 37.91 ± 5.40 29.28 ± 3.59 22.99 ± 2.51 <0.001
GFR 6 months after RSP initiation 46.99 ± 15.42 38.88 ± 9.98 31.24 ± 7.80 <0.001
ΔGFR (% change) 9.08 ± 13.44 (23.95%) 9.60 ± 9.19 (32.79%) 8.25 ± 7.56 (35.89%) 0.921
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To cite this abstract in AMA style:

Patel N, Kittleson M, Patel J, Singer-Englar T, Kim S, Chang D, Azarbal B, Nikolova A, Czer L, Esmailian F, Kobashigawa JA. When is the Optimal Time to Initiate the Renal-Sparing Protocol with Calcineurin Inhibitor Withdrawal? [abstract]. Am J Transplant. 2021; 21 (suppl 3). https://atcmeetingabstracts.com/abstract/when-is-the-optimal-time-to-initiate-the-renal-sparing-protocol-with-calcineurin-inhibitor-withdrawal/. Accessed May 31, 2025.

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