Tacrolimus for rescue of refractory renal allograft rejection.

SIGNIFICANT improvements in the results of renal transplantation in the 1980s were largely due to the development of cyclosporine (CyA) and the use of antilymphocyte agents for induction protocols and/or treatment of rejection. However, rejection refractory to treatment with corticosteroids and/or antilymphocyte agents has remained a major obstacle to long-term success and account for a significant proportion of shortand long-term graft losses.1•2 Tacrolimus is a new immunosuppressant that has undergone extensive clinical testing for efficacy in renal transplantation. In both U.S. and European multicenter trials,3.4 tacrolimus has been found to be associated with a significant reduction in acute rejection episodes. An additional proven advantage of tacrolimus includes steroid tapering and monotherapy in up to 60% of recipients.s Perhaps even more striking is the utility of this drug as a salvage agent for refractory renal allograft rejection.6 9 We reported that of 77 patients with refractory acute rejection on baseline cyclosporine (CyA) therapy, graft salvage with tacrolimus conversion could be achieved in 74%.8 An additional 92 patients were subsequently converted to tacrolimus to attempt graft salvage, bringing the total to 169 patients.9 We report here the results of this expanded experience with tacrolimus conversion for recalcitrant renal allograft rejection. Other reports from both single-center and multicenter studies have confirmed that tacrolimus provides an excellent alternative to corticosteroids and antilymphocyte preparations for the treatment of refractory renal allograft rejection and they form the basis of this discussion.