Tailor choice of calcineurin inhibitor to patients' own circumstances
Individual circumstances are crucial to deciding whether to use tacrolimus or ciclosporin as primary immunosuppresion for kidney transplant recipients, a meta-analysis suggests (BMJ 2005;331:810).
The analysis of 4,102 patients from 30 trials found that, compared with
ciclosporin, treatment with tacrolimus resulted in a 44 per cent reduction
in graft loss within the first six months and, within the first year,
a 31 per cent reduction in the number of patients experiencing acute
rejection and a 51 per cent reduction in the number suffering rejection
that needed treatment more intensive than steroids.
Treating 100 patients with tacrolimus instead of ciclosporin for the
first year after transplantation would, the authors calculate, avoid
12 patients suffering acute rejection and two losing their graft, but
it would cause an extra five patients to develop insulin-dependent diabetes.
A further meta-regression suggested that maintaining tacrolimus concentrations
below 10ng/ml would minimise graft loss and lessen the increased risk
of diabetes mellitus, without increasing the risk of acute rejection.
The authors argue that their analysis should be used to construct a decision
analysis tool. “This would provide clinicians and patients with
an algorithm trading off graft survival against the impact of diabetes
and other complications of immunosuppression, so tailoring the choice
of calcineurin inhibitor to an individual patient’s circumstances,” they
say. |
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