Immunosuppression protocol- CPG

41. IMMUNOSUPPRESSION PROTOCOL

41.1 The standard immunosuppression regimen
The standard immunosuppression regimen (adult1,2,3,10,11,12,13,14,15,16 and LRRT in children18) consists of tacrolimus / cyclosporin, mycophenolate mofetil (MMF) and prednisolone. (Level A)

41.1.1 The immunosuppression regimen may be modified in the following situations:
a. Polyclonal4,5/monoclonal antibody6 or anti-ILII antibody7,19,20 can be used as induction immunotherapy when acute tubular necrosis or delayed graft function is anticipated and in highly sensitised recipients. (Level A)
However Anti-IL II antibody has minimal side effects and is easier to use.4
b. In highly sensitised recipients i.e. multiparous female, multiple blood transfusion and previous history of transplant, PRA >20%, cadaveric transplantation in children, tacrolimus may be used instead of cyclosporin,8,9, and/or the use polyclonal5/monoclonal antibody 6 or anti-ILII antibody7,19,20 as induction immunotherapy.

41.2 Immunosuppressive agents
41.2.1 Corticosteroids
a. Hydrocortisone 200 mg IV stat on call to theatre and post-operatively and 8-hourly until patient is tolerating orally
b. IV Methylprednisolone 500 mg at anastomosis for cadaveric renal transplant in addition to the above
c. Hydrocortisone is replaced by prednisolone 20 mg daily when allowed orally
d. Prednisolone is tapered off beginning at 3 months post-transplant, by 2.5 mg per month till the dose of 10 mg daily is reached
e. Prednisolone may be reduced to 5 – 7.5 mg daily in selected patients (e.g. stable recipient with severe steroid toxicity)

41.2.2 Cyclosporin
a. For living related renal transplantation, Neoral 8 mg/kg/day to begin 5 days pre-transplant
b. For cadaveric transplant, dose of Neoral is 10 mg/kg/day given pre transplant
c. Dose of Neoral is adjusted according to trough levels or C2

Trough levels
• Less than 6 months post-transplant: 250-375 ng/ml
• 6 months or more post-transplant: 100-250 ng/ml
C2 levels
• Less than 1 month: 1.7 ug/ml
• 1-2 months: 1.5 ug/ml
• 2-3 months: 1.3 ug/ml
• 4-6 months: 1.1 ug/ml
• 7–12 months: 0.9 ug/ml
• more than 12 months: 0.8 ug/ml

41.2.3 Tacrolimus
a. For living related renal transplantation, tacrolimus 0.2 mg/kg/day to begin 5 days pre-transplant
b. For cadaveric transplant, dose of tacrolimus is 0.3 mg/kg/day given per oral when called to operating theatre.
c. Post-operatively, tacrolimus is given at 0.2 mg/kg/day in divided doses
d. Dose is adjusted according to trough levels:
• Less than 6 months post-transplant: 10-15 ng/ml
• 6 months or more post-transplant: 5-10 ng/ml

41.2.4 Mycophenolate mofetil
a. On call to theatre, mycophenolate mofetil is given 1 g per oral
b. Post-transplant, mycophenolate mofetil is given 1 g twice a day per oral (dose in children 600 mg/m2/dose 12 hourly)
c. Dose is reduced or omitted if total white counts are <> 8 yr
Oral MMF 300 mg/m2/dose stat dose before going to OT
Tacrolimus 0.1 mg/kg/dose b.d.
IV Methyprednisolone 600 mg/m2 BSA just prior to
anastomosis of renal vessels
D1 IV Hydrocortisone 5 mg/kg/dose tds
Oral MMF 300 mg/m2/dose bd
Tacrolimus 0.1 mg/kg/dose b.d.
D2 Prednisolone 60 mg/m2/day b.d. dosing
Oral MMF 300 mg/m2/dose bd
Tacrolimus 0.1 mg/kg/dose b.d.
D4 Repeat IV Basiliximab

41.3.2 Living Related Renal Transplant
D – 5 Oral Cyclosporin 10 mg/kg/day in b.d. dosing or tacrolimus 0.2 mg/kg/day b.d.
Oral MMF 600 mg/m2/dose bd (reduced by 50% if used in combination with tacrolimus)
D0 IV Methyprednisolone 600 mg/m2 BSA prior to anastomosis
of vessels
Oral Cyclosporin 10 mg/kg/day in b.d. dosing or tacrolimus 0.2 mg/kg/day b.d.
Oral MMF 600 mg/m2/dose bd (reduced by 50% if used in combination with tacrolimus)
D1 IV Hydrocortisone 5mg/kg/dose tds
Oral Cyclosporin 10 mg/kg/day in b.d. dosing or tacrolimus 0.2 mg/kg/day b.d.
Oral MMF 600 mg/m2/dose bd (reduced by 50% if used in combination with tacrolimus)
D2 Prednisolone 60 mg/m2/day bd dosing
Oral Cyclosporin 10 mg/kg/day in b.d. dosing or tacrolimus 0.2 mg/kg/day b.d.
Oral MMF 600 mg/m2/dose bd (reduced by 50% if used in combination with tacrolimus)

41.3.3 Guidelines for drug dose tapering in paediatric renal transplant recipients
a. Cyclosporin / tacroloimus – follow adult schedule
b. Prednisolone - start tapering the dose 1 week post-transplant and taper 10 mg/week till 10 – 12.5 mg daily if renal function is stable and cyclosporin / tacrolimus is within the desired range.




References
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