The main aims of these protocols are to reduce the incidence of early acute rejection and to optimise long-term allograft function.
As patients return to their local Renal Units post-transplantation, it is the responsibility of the local nephrology teams to tailor immunosuppression in the long-term. Options for maintenance therapy are outlined below.
At the outset, it is important to grade patients according to both immunological risk and their risk of delayed graft function, with the aim of tailoring immunosuppression accordingly.
Scoring system for immunological risk
|HLA-DR mismatch = 1|
|DSA only by Luminex =1|
|DSA present resulting in positive Flow XM = 2|
|Regraft with loss to rejection < 1yr = 2|
|Score = 0 = Low immunological risk|
|Score = 1 = Moderate Immunological risk|
|Score > 1 = High Immunological risk|
Scoring system for Marginal donor-risk of DGF
|Consider as Marginal Graft if Marginal Tx Score > 1|
|Donor – Age > 60 < 65 = 1|
|Donor – NIDDM/IDDM = 1|
|Donor – Hypertension =1|
|Donor – Vascular Disease =1|
|Donor – Cold Ischaemia > 24 hrs =1|
|Donor – Donation after circulatory death (DCD) = 2|
|Donor – Age > 65 = 2|
|Donor Graft > 20% Sclerosed Gloms on donor biopsy =2
Immunosuppressive regime: all renal transplants
I. Standard Regimen
This regimen applies to all first, unsensitised cadaveric graft recipients with low immunological risk.
|Pre-op||Mycophenolate mofetil (MMF) PO 1g|
|(at admission)||Tacrolimus (Prograf®) PO 0.05mg/kg|
|Peri-op||Basiliximab IV 20mg|
|Methylprednisolone IV 500mg in theatre;|
|And 500mg 24hrs post-op|
|Post-op||Prednisolone PO 20mg daily (to 5mg at 3 months)|
|MMF PO 1g bd at 08:00 and 20:00|
|Tacrolimus (Prograf®) 0.05mg/kg bd at 10:00 and 22:00|
|Day 4||Basiliximab IV 20mg|
II. Moderate risk patients
Only difference is the target trough tacrolimus level.
The same initial dose is given, and adjusted according to serum levels
- target trough level 8-12 in first 3 months
- target trough level 5-10 after 3 months
III. High risk
It is important to identify patients who are at high immunological risk at the time of listing where possible.
A tailored immunosuppressive regimen should be decided at the monthly MDT, and a clear plan documented in the patient’s notes.
In these cases, consideration should be given to:
- Induction therapy with ATG (as per protocol page)/ Alemtuzumab (Mabcampath®) SC 30mg
- In these cases, such therapy replaces basiliximab
- Monitoring of antibody levels post-operatively where there is a known donor specific antibody, and intervention with plasma exchange and/or IVIg as necessary.
- Tacrolimus as standard dose with target levels 8-12
- Prednisolone and MMF are prescribed as above.Early biopsy of these transplanted kidneys should be carefully considered.
Recipients of Marginal grafts: (as per scoring system)
Standard immunosuppression, with target trough tacrolimus levels of 5-7mg/dl if patient is low immunological risk.
If patient is at moderate or high immunological risk, immunosuppression should be prescribed according to that protocol.
Live Donor Renal Transplant recipients:
The same protocols apply as for deceased donor transplants.
Tacrolimus and MMF are commenced at the time of admission of patients for live donor transplants
Defined as a biopsy carried out at a fixed time point irrespective of other parameters.
This is strongly recommended in:
- High immunological risk patients, particularly those with DSA pre-transplant
- Previous graft lost to AR
- Recipient with an episode of early acute rejection
- Patients with high risk of recurrent disease
- De novo DSA
The optimal time period whereby results may impact management is within 3 – 6 months of transplant.