Comment: The quality of evidence is downgraded by study limitations (most were open-label studies; 70% had unclear allocation concealment and half of the trials were commercially funded).
A Cochrane review [Abstract] 1 included 83 studies with a total of 16 156 subjects with kidney transplant recipients. In calcineurin inhibitors (CNI) withdrawal group, there were more rejections but little or no difference in mortality T1. Calcineurin inhibitor (CNI) withdrawal and use of mammalian target of rapamycin inhibitor (mTORi) versus standard dose CNI resulted in more acute rejections but no clear difference in mortality or graft loss T2.
| Outcome | Relative effect (95% CI) | Risk with control - Standard dose CNI | Risk with intervention - CNI withdrawal (95% CI) | No. of participants (studies) Quality of evidence |
|---|---|---|---|---|
| Death Follow-up: range 9 months to 20 years | RR 1.09 (0.96 to 1.24) | 225 per 1000 | 245 per 1000 (216 to 279) | 2010 (14) Moderate |
| Acute rejection Follow-up: range 9 months to 15 years | RR 2.54 (1.56 to 4.12) | 137 per 1000 | 348 per 1000 (214 to 564) | 1666 (15) Moderate |
| Graft loss Follow-up: range 9 months to 20 years | RR 0.85 (0.74 to 0.98) | 236 per 1000 | 201 per 1000 (175 to 231) | 2090 (16) Low |
| Adverse events: hypertension Follow-up: range 1 to 15 years | RR 0.82 (0.71 to 0.95) | 555 per 1,000 | 455 per 1,000 (394 to 527) | 950 (5) Low |
| Outcome | Relative effect (95% CI) | Risk with control - Standard dose CNI | Risk with intervention - CNI withdrawal plus mTORi (95% CI) | No. of participants (studies) Quality of evidence |
|---|---|---|---|---|
| DeathFollow-up: range 6 months to 5 years | RR 0.99(0.69 to 1.40) | 26 per 1000 | 26 per 1000(18 to 36) | 5427 (23) Moderate |
| Acute rejectionFollow-up: range 6 months to 5 years | RR 1.43(1.15 to 1.78) | 134 per 1000 | 191 per 1000(154 to 238) | 5903 (30) Moderate |
| Graft lossFollow-up: range 1 to 5 years | RR 0.94(0.75 to 1.19) | 53 per 1000 | 50 per 1000(40 to 64) | 5446 (25) Low |
| Adverse events: hypertensionFollow-up: range 6 months to 5 years | RR 0.86(0.64 to 1.15) | 218 per 1000 | 187 per 1000(139 to 250) | 2207 (7) Low |
| Adverse events: CMV Infectionfollow-up: range 6 months to 5 years | RR 0.60(0.44 to 0.82) | 150 per 1000 | 90 per 1000(66 to 123) | 2503 (13) Moderate |
Date of latest search: July 2017
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