Mycophenolate mofetil versus azathioprine for prevention of chronic allograft dysfunction in renal transplantation: The MYSS follow-up randomized, controlled clinical trial

The Mycophenolate Steroids Sparing (MYSS) study found that in renal transplant recipients who were on immunosuppressive therapy with the cyclosporine microemulsion Neoral, mycophenolate mofetil (MMF) was not better than azathioprine in preventing acute rejection at 21 mo after transplantation and was 15 times more expensive. The MYSS Follow-up Study, an extension of MYSS, was aimed at comparing long-term outcome of 248 MYSS patients according to their original randomization to MMF (1 g twice daily) or azathioprine (75 to 100 mg/d). Primary outcome was estimated GFR at 5 yr after transplantation. Mean 5-yr GFR difference between azathioprine and mycophenolate was 4.67 ml/min per 1.73 m² (95% confidence interval [CI] -0.43 to 9.77 ml/min per 1.73 m²; P = 0.07). GFR from month 6 (mean ± SEM: 54.3 ± 1.6 versus 53.9 ± 1.5 ml/min per 1.73 m²; P = 0.83) to month 72 after transplantation (49.5 ± 2.2 versus 47.3 ± 2.4 ml/min per 1.73 m²; P = 0.50); GFR slopes (mean ± SEM: -1.10 ± 0.56 versus -1.23 ± 0.31 ml/min per 1.73 m² per year; P = 0.83); and 72-mo patient mortality (4.0 versus 4.0% [P = 0.95]; HR 0.96; 95% CI 0.28 to 3.31; P = 0.95), graft loss (6.8 versus 6.1% [P = 0.82]; HR 0.89; 95% CI 0.32 to 2.46; P = 0.83), incidence of persistent proteinuria (25.0 versus 27.4%; P = 0.72), late (>6 mo after transplantation) rejections (25.3 versus 21.2%; P = 0.53), and adverse events were similar on azathioprine (n = 124) and MMF (n = 124), respectively. Outcomes in the two groups were comparable also among patients with or without steroid therapy, considered separately. In kidney transplantation, the long-term risk/benefit profile of MMF and azathioprine therapy in combination with cyclosporine Neoral is similar. In view of the cost, standard immunosuppression regimens for kidney transplantation should perhaps include azathioprine rather than MMF.