Clearly, there are risks and benefits of using Campath in renal transplantation. Has the drug met your expectations or wait to have further supporting evidences.
We have switched in 2011, from Thymoglobulin induction to Campath induction, after decades of using Thymoglobulin. We did so for two important reasons: First, we wanted to eliminate steroids in our maintenance, and second, we felt it was cheaper and simpler than a course of thymoglobulin. We have been very satisfied. We use Campath in all primary transplants, except in cases of highly matched living donor recipients. We give one dose of 30 mg intra-op, accompanied by 500mg solumedrol. That's our entire induction. Maintenance is Myfortic and Advagraf. Low levels observed from the beginning. What we have seen is actually a rise in the incidence of acute rejection - but the rejections are generally easy to manage. Those patients are declared failures of the steroid withdrawal and go onto a maintenance regime. This was a surprise to us, but we were aware that increased acute rejection was suggested by meta-analyses of steroid-avoidance. On the other hand, our incidence of BK virus has plummeted from about 8% to less than 4%. We are quite happy with our outcomes. If anything, the patients are suffering fewer complications of immunosuppression. I would say Campath is quite safe for induction and allows for rapid withdrawal of steroids. It is less expensive than thymo and far easier to administer, making discharge planning very simple.
Thank you very much Dr Paraskevas for sharing your experience of using Campath in your Unit, which is extremely helpful. You have very clearly shown the advantages of using Campath. Very much apppreciated. Best wishes. Badri
You are most welcome. I should correct my figures on the BK viremia. The incidence of viremia was actually much much higher with the Thymo/steroids protocol, and the reduction we have seen has been very dramatic. In terms of actual nephropathy, we are in the 5-8% range and this is also significantly reduced. I ascribe these changes to the steroid avoidance rather than the choice of induction agent, but there is no doubt that campath has simplified our induction and taken a great deal of the 'guess work' out of it. This is something that all house staff and nursing staff also appreciate.
Could sure be useful, but to date not on evidence based medicine
I agree no evidence base at present. The 3C study will address this but the large American centres have largely stopped using CAMPATH after early enthusiasm. I would suggest you might want to contact Luis Fernandez (University of Wisconsin, Madison) who has enormous experience of clinical use and I have found very helpful to discuss this. My own experience in pancreas transplant recipients has left me very guarded about the benefits. I have seen an excess of lymphoma (including unusual presentations) as compared to the kidney transplant recipients I managed who do not receive CAMPATH. Neutropenia is also common making close monitoring and titration of MMF dose essential. It can get very uncomfortable with no corticosteroid on board, MMF stopped because of low neutrophil counts so patients maintained on Tac monotherapy. At about 6 months there then seems to be recovery of leucocyte populations. This is manifest by neutrophil counts increasing but I guess other populations recover also as if you are not very on the ball and get the immunosuppression up, acute rejection will ensue. This is not frequent enough to be immediately obvious with small numbers of patients followed up, but happens often enough to matter. One consequence is the need for much more frequent monitoring than would be the norm if CAMPATH were not used right out to a year for some patients. Given that rejection is more difficult to diagnose and treat in pancreas transplantation (particularly PTA) I am comfortable that the risk benefit equation allows use of CAMPATH in this setting even without a definitive evidence base. I do not think this is true with kidney transplantation and would urge that we look beyond acute rejection. My feeling is that CAMPATH looks and feels very good to start with, then as numbers grow and patients are followed for longer, the down sides become clear.
Further to above I have attached a PowerPoint file with a few slides selected from a talk I gave summarising outcomes with the first 50 patients from the SW transplanted in Oxford and followed up by myself. Experience is now with >100 patients with same bottom line. Overall I think the results are excellent and I remained passionately supportive of this programme, but patients need to be transparently appraised of the risks. The patients who died of haematological complications (Lymphoma and ITP) were 1 PTA, 1 PAK recipient. Both young. No clear predisposing factors. Anecdote but I believe an important perspective.
Dear Dr Smith,
Many thanks for sharing your experience with us. I really appreciate your help.
Wish you and family a Merry Christmas.
Badri