Management of Immunosuppression in Critically Ill Renal Transplant Patients in the ICU: Immunologic and Overall Long-Term Outcome.

Background: Little data exists to guide the management of immunosuppression in critically ill patients in the ICU. Reduction of the immunosuppressive medication may reduce the risk of infection, but may consequently increase the risk of sensitization, rejection and graft failure. Methods: A retrospective long-term observational study of a well-characterized cohort of 140 consecutive kidney transplant patients admitted to the ICU between 2003 and 2013. Demographic and clinical data as well as long-term outcomes over a period of maximal 10 years after transplantation were assessed. Results: During ICU stay 58 patients received reduced immunosuppression as a monotherapy (mono IS), 82 patients received immunosuppressive therapy with multiple agents (multiple IS). The baseline characteristics of the two groups did not differ significantly. Patients with immunosuppression reduced to monotherapy during ICU-stay (mono IS) had significantly higher severity of illness scores than patients who received immunosuppression with multiple agents (multiple IS): APACHEII 22 vs. 17, p=0.004. Nevertheless 5-year mortality was not significantly different (both groups 39%, logrank p=0.771). Between the groups (mono IS vs. multiple IS) there was no significant difference in the occurrence of de novo donor-specific HLA-antibodies (12% vs. 11%, p=1.000), rejections (9% vs. 7%, p=0.762), baseline creatinine 1 year post-ICU (2.1 vs 1.9 mg/dl, p=0.322) and 5 years post-ICU (1.7 vs. 1.9 mg/dl, p=0.935). Conclusions: Reduction of immunosuppression in critically ill renal transplant patients on ICU may reduce complications without resulting in a significantly higher risk of sensitization, rejections and graft failures.Figure: No Caption available.