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Joanna Major, Jacek P. Szaflik, Mieczyslaw Lao, Jerzy Szaflik; Results Of Systemic Immunosuppresion (SI) In High Risk Penetrating Keratoplasty (HRPK). Invest. Ophthalmol. Vis. Sci. 2011;52(14):372.
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HRPK remains challenging due to risk of allograft rejection. Introduction of immunosuppressives (mycophenolate mofetil - MMF, tacrolimus, cyclosporine A - CsA) made it possible to extent corneal graft survival.
From January 2009 to March 2010 35 patients had SI administered contemporaneously with keratoplasty. Indications for IS were repeated allotransplatations, coexistence of local or multiorgan immunopathies. Some patients had 2 or more risk factors. SI was introduced after excluding possible contraindications. The double drug therapy (S + MMF) was introduced in most of the cases: steroids (S) i.v. followed by oral tapered doses of prednisone/methylprednisone (P/MP), MMF in initial dose of 1000 mg b.i.d adjusted to reach predose (C0) of MPA concentration of 2- 4 µg/ml. In some cases (3rd or 4th corneal transplantation due to graft failure) tripple therapy: S + MMF + CsA (S. Neoral 3 mg/kg and tapered to reach C0 100ng/ml) was administered. Prophylaxis for 6 months with acyclovir (2 x 800 mg) and Co-trimazole (2 x 480 mg) was introduced. Topical treatment consisted of loteprendol etabonate, quinolone, mydriatics and lubricants. SI was tapered: S to the dose of 5/4 mg of P/MP o.d, CsA and MMF were withdrawn after 6-8 and 12-14 months accordingly.
No graft rejection was observed during IS. Best corrected visual acuity (BCVA) was from counting fingers (1 patient) to 0.7, average 0.32 examined 5-14 months (average 9.7) after surgery. Over 90% (n= 32) of the patients were IgG (+) for CMV however none of them were IgM (+) prior to therapy. 2 patients developed leucopenia resolving after MMF dose reduction and 2 had moderate increase of serum creatinine concentration controlled by CsA dose reduction. 1 patient died of colon cancer with metastases to liver (she was asymptomatic prior to KP, had negative history of gastric problems, negative benzidine and cancer antigens tests, negative colonoscopy). Neocancerogenesis due to MMF use cannot be excluded but it seems unlikely because MMF is considered less active in cancerogenesis than CsA and treatment of 6 months is to short to induce the process. 2 patients resigned.
IS is a valuable treatment option increasing graft survival in HRPK.
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