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Transplant Rev (Orlando). 2019 Jul 23. pii: S0955-470X(19)30035-7. doi: 10.1016/j.trre.2019.07.001. [Epub ahead of print]

Evidence-based practice: Guidance for using everolimus in combination with low-exposure calcineurin inhibitors as initial immunosuppression in kidney transplant patients.

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Department of Nephrology, Hospital del Mar, Barcelona, Spain. Electronic address:
Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
Renal Medicine, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia.
Department of Surgery, Renal Transplantation, Catholic University, Rome 00168, Italy.
Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, University Paul Sabatier, Toulouse, France.
Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation, Rotterdam, the Netherlands.
Paris Translational Research Center for Organ Transplantation, INSERM U970, Necker Hospital University Paris Descartes, Paris, France.
Department of Nephrology, University Duisburg-Essen, University Hospital Essen, Essen, Germany.
Department of Nephrology, Hospital Clinic, Barcelona, Spain.
Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia.
Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany.
Kidney and Pancreas Transplant Unit, Padua University Hospital, Padua, Italy.
Division of Nephrology, Intermountain Healthcare, Salt Lake City, UT, USA.
Department of Transplant Nephrology and Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
Department of Surgery, The Comprehensive Transplant Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
Department of Surgery, Kidney Transplant Service, University of California, San Francisco, CA, USA.
Division of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo 04038-002, Brazil. Electronic address:


The mammalian target of rapamycin (mTOR) inhibitor, everolimus, in combination with reduced-exposure calcineurin inhibitor (CNI), has been demonstrated in clinical trials to have comparable efficacy in low-to-moderate immunological risk kidney transplant recipients to the Standard of Care, mycophenolic acid (MPA) in combination with standard-exposure CNI. Current treatment guidelines consider mTOR inhibitors to be a second-line therapy in the majority of cases; however, given that everolimus-based regimens are associated with a reduced rate of viral infections after transplantation, their wider use could have great benefits for kidney transplant patients. In this evidence-based practice guideline, we consider the de novo use of everolimus in kidney transplant recipients. The main outcomes of our consideration of the available evidence are that: 1. Everolimus, in combination with reduced-exposure CNI and low dose steroids, is a suitable regimen for the prophylaxis of kidney transplant rejection in the majority of low-to-moderate immunological risk adult patients, with individualized management; 2. Induction with either basiliximab or rabbit anti-thymocyte globulin is an effective therapy for kidney transplant recipients when initiating an everolimus-based, reduced-exposure CNI regimen; and 3. An individualized approach should be adopted when managing kidney transplant recipients on everolimus-based therapy.


Everolimus; Guidelines; Kidney; Transplantation; mTOR inhibitor/mTORi


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