Clinical outcome in heart transplant recipients with chronic kidney disease after introduction of calcineurin inhibitor free immunosuppressive therapy

Aims: Calcineurin inhibitors (CNIs) have nephrotoxic side effects. In heart transplant (HTx) recipients, CNI-free immunosuppressive therapy with Everolimus (EVL) and Mycophenolic-acid (MPA) derivatives seems to be a reliable treatment option for avoiding end-stage chronic kidney disease (CKD).

Methods: Between January 2010 and October 2010 we switched 13 HTx recipients with CKD stages 3–4 from low-dose CNI plus EVL over to MPA plus EVL. Kidney function, blood cell counts and clinical outcome were evaluated during a 6-month follow-up period.

Results: Three patients developed a herpes zoster-induced thoracic infection. One other patient developed pneumonia. The patient with pneumonia died of a septic shock 42 day after the introduction of MPA plus EVL. No cardiac rejection occurred. Mean creatinine levels decreased from 2.4mg/dl (range 1.7–2.5mg/dl) to 1.7mg/dl (range: 1.0–2.2mg/dl) (p<0.001), whereas mean glomerular filtration rate increased from 28.9ml/min/1.73m² (range: 19–40ml/min/1.73m²) to 43.4ml/min/1.73m² (range: 30–70ml/min/1.73m²) (p>0.001). Mean blood urea nitrogen decreased from 114mg/dl (range: 59–190mg/dl) to 80mg/dl (range:51–140mg/dl) (P=0.032). Blood cells counts remained stable.

Conclusion: In HTx patients with CNI-induced CKD stages 3–4, the introduction of MPA plus EVL was associated with moderate beneficial effects on kidney function. However, our data do not exclude the possibility that CNI-free immunosuppressive therapy with MPA is a risk factor for the occurrence of infections.