الفهرس 
Risk of chronic renal allograft nephropathyOnly 14 pages are availabe for public view
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Abstract
Among different centers, current practices which were once monotonously uniform are now increasing singly diverse. However, there remain at least two common themes; first is commitment to combination therapy; in general combination of immunosuppressives that target different pathways in the rejection response allow administration of lower doses of each providing effective immunosuppression with fewer drug- specific adverse events. However, given the potency of currently available agents, caution is necessary to avoid over immunosuppression in administrating such protocols. Second, is the ongoing appreciation of the impact of acute rejection remains a strong predictor of intermediate and long term graft failure The goal of most current protocols is to prevent rather to treat acute rejection The objective of this work is critical analysis of different immunosuppressive protocols in live-donor kidney transplant recipient in a retrospective study. The material of this work included 1392 live-donor kidney transplant recipients who were carried out in the Urology and Nephrology Center, Mansoura University from (1976-2001). There was statistically significant difference was found regarding incidence of hypertension and number of drugs used to control hypertensive patients in triple group. The overall graft survival was 75.8% at 5 years and the corresponding patient survival was 85.4%. In general, renal transplantation from living donors offers a 10-15% advantage of graft survival over cadaveric sources at 5 years. Our study aimed to compare results of one haplotype mismatched live donor renal transplantation on triple primary immunosuppressive regimen with a homogenous group, of different other primary immunosuppressive regimens namely double therapy consists of two immunosuppressive agents(e.g. azathioprine and prednisone) & (e.g. cyclosporine and prednisone) as well as triple therapy (CsA, MMF and prednisone) . Comparing azathioprine and prednisone versus triple thery we found marked reduction in acute rejection and its severity in triple therapy versus steroid+aza. We reported the incidence of biopsy proven chronic allograft nephropathy to be lower in calcineurin free regimen but not significant (36% P=0.24). Estimation of renal allograft function by serum creatinine and calculated GFR revealed better renal function in Steroid + Aza group but it did not rank to statistical significance(P=0.13). Comparing steroid+CsA versus triple thery we noticed there was significant reduction in frequency of acute rejection episodes with triple therapy (p=0.02) which reflected upon better graft and patient survival. The incidence of biopsy proven acute rejection and chronic allograft nephropathy was highly significant lower with usage of MMF and also its severity and the same result was achieved with triple therapy. Censored graft survival using (steroid+CsA+MMF) versus triple therapy was significantly improved and patient survival was highly significant better in (steroid+CsA+MMF) group. As a developing country, the cost of immunosuppressive regimens constitutes a major problem. The dialysis program costs much more than transplantation. The economic impact of therapies has increasingly become part of the clinical decision-making process. Costs associated with kidney transplantation are substantial and economic evaluations are useful in identifying immunosuppressive regimens that yield optimal clinical and economic benefits. In our study the economic analysis showed that the daily and yearly cost of primary immunosuppression were highest in the rapamycine group compared with patients receiving tacrolimus followed by cyclosporine group.The cheapest protocol of immunosuppressant protocol was steroid+aza. This study confirmed that concomitant administration of ketoconazole and cyclosporine in kidney transplant recipients is safe and well tolerated. This combination therapy not only reduces the treatment costs, but results in more stable graft function, easier control of hypertension and less skin fungal infection. Concomitant ketoconazole-tacrolimus administration in kidney transplant recipients for two years is safe, results in outstanding cost reduction and improves outcome. At 2 years, the dramatic decrease of tacrolimus dose after addition of ketoconazole was maintained. Nevertheless, the percentage dose reduction was slightly lower than that observed at 6 months. The percentage reduction of tacrolimus dose gradually increased during the early follow-up period to reach its maximum level (58.7%) in the 6th month. Thereafter, it showed a slight decrease and remained stable till the 2nd year (53.8%). In this study, we confirmed after 10-years follow-up the continuity of CsA dose reduction and cost-savings we also found that the incidence of acute rejection episodes was similar in both the keto and control groups We found that the incidence of chronic allograft nephropathy (CAN) during the first year of follow-up was significantly less in the keto group compared to the control group. The potential benefits of induction therapy using anti-T-cell antibodies have been established. However, the utilization of these agents could be associated with several side effects .Basiliximab induction significantly reduces the incidence of acute rejection; its beneficial long term effects on graft function and patient and graft survival are not yet evident. We thought that multicentric double-blinded studies including a large number of patients are warranted to test the benefits of routine basiliximab induction on the long-term renal transplant outcome. Single bolus ATG induction significantly reduces the incidence of acute rejection; its long-term beneficial effects on graft function and patient and graft survival are not yet evident. We thought that a multicentric double blinded studies including large number of patients are warranted to test the benefits of routine ATG induction on the long-term renal transplant outcome.