Mycophenolate mofetil versus azathioprine in kidney transplant recipients on steroid-free, low-dose cyclosporine immunosuppression (ATHENA): A pragmatic randomized trial

Piero Ruggenenti, Paolo Cravedi, Eliana Gotti, Annarita Plati, Maddalena Marasà, Silvio Sandrini, Nicola Bossini, Franco Citterio, Enrico Minetti, Domenico Montanaro, Ettore Sabadini, Regina Tardanico, Davide Martinetti, Flavio Gaspari, Alessandro Villa, Annalisa Perna, Francesco Peraro, Giuseppe Remuzzi

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BackgroundAU : Pleaseconfirmthatallheadinglevelsarerepresentedcorrectly: We compared protection of mycophenolate mofetil (MMF) and azathioprine (AZA) against acute cellular rejection (ACR) and chronic allograft nephropathy (CAN) in kidney transplant recipients on steroid-free, low-dose cyclosporine (CsA) microemulsion maintenance immunosuppression. Methods and findings ATHENA, a pragmatic, prospective, multicenter trial conducted by 6 Italian transplant centers, compared the outcomes of 233 consenting recipients of a first deceased donor kidney transplant induced with low-dose thymoglobulin and basiliximab and randomized to MMF (750 mg twice/day, n = 119) or AZA (75 to 125 mg/day, n = 114) added-on maintenance low-dose CsA microemulsion and 1-week steroid. In patients without acute clinical or subclinical rejections, CsA dose was progressively halved. Primary endpoint was biopsy-proven CAN. Analysis was by intention to treat. Participants were included between June 2007 and July 2012 and followed up to August 2016. BetweenAU -group: PleaseconfirmthattheeditstothesentenceBetween donor and recipient characteristics, donor/recipient groupdonorandrecipientcharacterist mismatches, and follow-up CsA blood levels were similar. During a median (interquartile range (IQR)) followup of 47.7 (44.2 to 48.9) months, 29 of 87 biopsied patients on MMF (33.3%) versus 31 of 88 on AZA (35.2%) developed CAN (hazard ratio (HR) [95% confidence interval (CI)]: 1.147 (0.691 to 1.904, p = 0.595). Twenty and 21 patients on MMF versus 34 and 14 on AZA had clinical [HR (95% CI): 0.58 (0.34 to 1.02); p = 0.057) or biopsy-proven subclinical [HR (95% CI): 1.49 (0.76 to 2.92); p = 0.249] ACR, respectively. Combined events [HR (95% CI): 0.85 (0.56 to 1.29); p = 0.438], patient and graft survival, delayed graft function (DGF), 3-year glomerular filtration rate (GFR) [53.8 (40.6;65.7) versus 49.8 (36.8;62.5) mL/min/1.73 m2, p = 0.50], and adverse events (AEs) were not significantly different between groups. Chronicity scores other than CAN predict long-term graft outcome. Study limitations include small sample size and unblinded design. Conclusions In this study, we found that in deceased donor kidney transplant recipients on low-dose CsA and no steroids, MMF had no significant benefits over AZA. This finding suggests that AZA, due to its lower costs, could safely replace MMF in combination with minimized immunosuppression.AU : Anabbreviationlisthasbeencompiledforthoseusedthroughoutthearticle:Pleasev Trial registration NCT00494741; EUDRACT 2006-005604-14.

Original languageEnglish
Article numbere1003668
JournalPLoS Medicine
Issue number6
StatePublished - Jun 2021


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