Immunosuppression protocols

Immunosuppression is tailored according to an assessment of the patients’ immunological risk. It is more intense in the first few weeks and months when the risk of acute rejection is greatest, but needs to continue long-term. After transfer back to local units post-transplantation, the local nephrology team adjusts immunosuppression.

This page deals with immunosuppression in the first few months. There are sub-pages on Tacrolimus levels, on Steroid avoidance and withdrawal, and on Long-term immunosuppression.

See also the timepoint summaries under Outpatient Management indicating expectations at 3, 6 and 9 months.

Assessing immunological risk

We divide patients into high, standard and low immunological risk categories. The clinical relevance of this is that induction differs as per group.

We base ‘high’ immunological risk on the presence of donor-specific anti-HLA antibodies (DSA). These patient should receive ATG as induction.

Transplantation will usually not proceed if a full crossmatch is positive, except in very unusual and carefully planned circumstances. All positive crossmatch or DSA positive cases should be discussed with the H&I team to determine risk and their assessment on pathogenicity of the antibody. Standard risk patients will receive basiliximab induction. Low risk patients will not receive induction, other than IV methylprednisolone that all patients receive.

High risk: positive DSA or flow (FACS) crossmatch

For details on the ATG induction regime please see here. Indicates presence of donor-specific antibodies (DSA) measured by solid phase assay with or without a corresponding positive crossmatch.

  • Irrespective of number or class of antibody
  • No MFI cut-off stated
  • Current or historic

Standard risk

Basiliximab should be given for standard risk patients, based on KDIGO risk criteria, and include patients where any of the following circumstances apply:
  • recipient age <30 years, 
  • donor age ≥60 years, 
  • cRF >0%, 
  • 5-6 HLA-A-B-DR mismatches or 2 HLA-DR mismatches,
  • cold ischaemia time >24h, (predicted to be)
  • ABO incompatible

Low risk

All other patients not fulfilling these criteria should not receive antibody induction. There will still receive IV methylprednisolone like all other patients however.

 

Immunosuppressive regimen

This regimen applies to all recipients with standard immunological risk.

From Sep 2018, Edinburgh switched to use the Adoport® formulation of Tacrolimus in place of Prograf®. Formulations of Tacrolimus are not interchangeable and must be prescribed as a specific proprietary product. The age for reducing the standard MMF dose was also reduced from 65 to 60.

Pre-op
(at admission)
Peri-op
  • Basiliximab IV 20mg (or no induction if low risk)
  • Methylprednisolone IV 500mg in theatre;
    • and another 500mg 24hrs post-op
Post-op
  • Prednisolone PO 20mg daily (reducing to 15 mg at week 4, 10 mg at week 8, 5mg at 3 months. Restart clock if high dose steroid pulses given).
  • Mycophenolate mofetil (MMF) PO 1g bd at 10:00 and 22:00 (MMF 500mg twice daily if >60 years)
  • Tacrolimus (Adoport) 0.05mg/kg bd at 10:00 and 22:00
Day 4

Surveillance biopsy

This is a biopsy carried out at a fixed time point irrespective of other parameters. We rarely do these but they may be considered in:

  • High immunological risk patients, particularly those with DSA pre-transplant/positive flow (FACS) crossmatch
  • Previous graft lost to early acute rejection
  • ABO incompatibility
  • 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 unclear but generally within 3-6 months of transplant.