Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta‐Analysis. Issue 7 (15th March 2016)

• Record Type: Journal Article
• Authors: Sawinski, D.; Trofe‐Clark, J.; Leas, B.; Uhl, S.; Tuteja, S.; Kaczmarek, J. L.; French, B.; Umscheid, C. A.
• Is Part Of: American journal of transplantation. Volume 16:Issue 7(2016:Jul.)
• Page Start: 2117
• Page End: 2138
• Publication Date: 2016-03-15
• Subjects: clinical research/practice -- health services and outcomes research -- kidney transplantation/nephrology -- immunosuppressant -- calcineurin inhibitor (CNI) -- immunosuppressive regimens; Transplantation of organs, tissues, etc -- Periodicals; 617.95
• DOI: 10.1111/ajt.13710
• Languages: English
• ISSNs: 1600-6135

Abstract

Abstract : Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta‐analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate‐ to high‐strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard‐dose regimens; moderate‐strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate‐ to high‐strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine‐based strategies and low‐risk populations. Additional research is needed with tacrolimus‐based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient‐centered outcomes. Abstract : This systematic review and meta‐analysis examines calcineurin inhibitor minimization, conversion, withdrawal and avoidance strategies in renal transplant patients, and finds better clinical outcomes for minimization and increased risk of rejection associated with conversion and withdrawal.