Annals of
Intensive Care volume 15, Article number: 116, Published: 10
August 2025
Background
Sepsis is the leading cause of Intensive Care Unit (ICU)
admissions in kidney transplant recipients (KTRs). However, the optimal
immunosuppressive therapy (IST) management in this context is not well-defined.
We aimed to evaluate the impact of IST management in the ICU on mortality rates
and kidney graft function 6 months after inclusion in KTRs admitted for sepsis.
Methods
We conducted a multicenter, prospective, observational study
over 1 year in 11 French ICUs. Inclusion criteria were all KTRs who have been
transplanted for at least 3 months, admitted to the ICU for sepsis. All
changes of IST (7 days prior to ICU admission or throughout the ICU stay)
were collected. The primary outcome was MAKE 180 (Major Adverse Kidney Event),
a composite outcome including mortality, kidney graft dysfunction and dialysis
requirement at 180 days after inclusion.
Results
One hundred and twenty-four patients were included. The main
cause of ICU admission was respiratory failure for 78 patients (62.9%).
Predominant IST management was mycophenolic acid (MPA) discontinuation for 74
patients (59.7%) and calcineurin inhibitor (CNI) continuation for 63 patients
(50.8%). By multivariable analysis, after adjustment for age, non-renal SOFA
score at admission, kidney function at admission, sex, and history of cellular
rejection we did not find any significant association between MAKE 180 and CNI
discontinuation (adjusted OR = 1.05, 95% CI 0.87–1.26, p = 0.6). In contrast, MPA
discontinuation was significantly associated with MAKE 180 (adjusted OR = 1.45,
95% CI 1.07–1.96, p = 0.018). No significant
association was found between IST discontinuation and ICU-acquired infections
(adjusted OR = 1.14, 95% CI 0.95–1.36, p = 0.157). Among ICU survivors,
only 2 graft rejections occurred during the year following ICU discharge.
Conclusion
This study is the first prospective investigation to suggest
an association between MPA discontinuation and adverse outcomes during sepsis
in critically-ill KTRs. These findings must be interpreted with caution given
the potential confounding introduced by SARS-Cov-2–specific treatment
protocols. Further interventional trials are necessary to optimize
immunosuppressive drug strategies in KTRs during sepsis.