Immunosuppression in the elderly renal allograft recipient: a systematic review

Nuria Montero; María José Pérez-Sáez; Julio Pascual; Daniel Abramowicz; Klemens Budde; Chris Dudley; Mark Hazzan; Marian Klinger; Umberto Maggiore; Rainer Oberbauer; Julio Pascual; Soren S Sorensen; Ondrej Viklicky; DESCARTES Working Group

doi:10.1016/j.trre.2016.05.001

Immunosuppression in the elderly renal allograft recipient: a systematic review

Nuria Montero, María José Pérez-Sáez, Julio Pascual, Daniel Abramowicz, Klemens Budde, Chris Dudley, Mark Hazzan, Marian Klinger, Umberto Maggiore, Rainer Oberbauer, Julio Pascual, Soren S Sorensen, Ondrej Viklicky, DESCARTES Working Group

Department of Clinical Medicine

20 Citations (Scopus)

Abstract

BACKGROUND: The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown.

METHODS: We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed.

RESULTS: Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended.

CONCLUSIONS: There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.

Original language	English
Journal	Transplantation Reviews
Volume	30
Issue number	3
Pages (from-to)	144-153
Number of pages	10
ISSN	0955-470X
DOIs	https://doi.org/10.1016/j.trre.2016.05.001
Publication status	Published - 1 Jul 2016

Keywords

Journal Article
Review

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10.1016/j.trre.2016.05.001

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Montero, N., Pérez-Sáez, M. J., Pascual, J., Abramowicz, D., Budde, K., Dudley, C., Hazzan, M., Klinger, M., Maggiore, U., Oberbauer, R., Pascual, J., Sorensen, S. S., Viklicky, O., & DESCARTES Working Group (2016). Immunosuppression in the elderly renal allograft recipient: a systematic review. Transplantation Reviews, 30(3), 144-153. https://doi.org/10.1016/j.trre.2016.05.001

Montero, N, Pérez-Sáez, MJ, Pascual, J, Abramowicz, D, Budde, K, Dudley, C, Hazzan, M, Klinger, M, Maggiore, U, Oberbauer, R, Pascual, J, Sorensen, SS, Viklicky, O & DESCARTES Working Group 2016, 'Immunosuppression in the elderly renal allograft recipient: a systematic review', Transplantation Reviews, vol. 30, no. 3, pp. 144-153. https://doi.org/10.1016/j.trre.2016.05.001

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abstract = "BACKGROUND: The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown.METHODS: We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed.RESULTS: Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended.CONCLUSIONS: There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.",

keywords = "Journal Article, Review",

author = "Nuria Montero and P{\'e}rez-S{\'a}ez, {Mar{\'i}a Jos{\'e}} and Julio Pascual and Daniel Abramowicz and Klemens Budde and Chris Dudley and Mark Hazzan and Marian Klinger and Umberto Maggiore and Rainer Oberbauer and Julio Pascual and Sorensen, {Soren S} and Ondrej Viklicky and {DESCARTES Working Group}",

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doi = "10.1016/j.trre.2016.05.001",

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T1 - Immunosuppression in the elderly renal allograft recipient

T2 - a systematic review

AU - Montero, Nuria

AU - Pérez-Sáez, María José

AU - Pascual, Julio

AU - Abramowicz, Daniel

AU - Budde, Klemens

AU - Dudley, Chris

AU - Hazzan, Mark

AU - Klinger, Marian

AU - Maggiore, Umberto

AU - Oberbauer, Rainer

AU - Pascual, Julio

AU - Sorensen, Soren S

AU - Viklicky, Ondrej

AU - DESCARTES Working Group

PY - 2016/7/1

Y1 - 2016/7/1

N2 - BACKGROUND: The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown.METHODS: We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed.RESULTS: Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended.CONCLUSIONS: There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.

AB - BACKGROUND: The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown.METHODS: We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed.RESULTS: Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended.CONCLUSIONS: There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.

KW - Journal Article

KW - Review

U2 - 10.1016/j.trre.2016.05.001

DO - 10.1016/j.trre.2016.05.001

M3 - Review

C2 - 27279024

SN - 0955-470X

VL - 30

SP - 144

EP - 153

JO - Transplantation Reviews

JF - Transplantation Reviews

IS - 3

ER -

Immunosuppression in the elderly renal allograft recipient: a systematic review

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