The use of neostigmine to treat postoperative ileus in orthopedic spinal patients.

Ileus is a common complication of spinal surgery, affecting 5% to 12% of all patients. Often this ileus is secondary to acute colonic pseudo-obstruction. This study is a prospective clinical trial of neostigmine in seven spinal patients with ileus after surgery to demonstrate its efficacy. All patients had evidence of the Ogilvie syndrome that was unresponsive to 24 hours of conservative therapy. Patients received 2 mg neostigmine, and abdominal circumference, clinical response, and radiographic colonic measurements were recorded. Patients were followed for recurrence of ileus for their remaining time in the hospital. Six patients had prompt colonic decompression, and no patient had recurrence of colonic distension. Side effects were minimal. These results suggest that postoperative spinal patients with ileus secondary to acute colonic pseudo-obstruction that is unresponsive to conservative therapy benefit from treatment with neostigmine, resulting in safe, rapid decompression of the colon.     

Acute colonic pseudo-obstruction: a pharmacological approach.

Acute colonic pseudo-obstruction is a functional disorder that closely mimics mechanical large bowel obstruction, and in which inadvertent laparotomy carries a high mortality. Eleven such patients were treated by pharmacological manipulation of the autonomic innervation to the colon with guanethidine and neostigmine. Eight responded to treatment with passage of flatus and/or stool within 10 min with complete resolution of symptoms. In three patients the treatment failed. Postural hypotension occurred in only one patient and no other serious side-effect was apparent. This pharmacological approach to the management of acute colonic pseudo-obstruction is suggested as an alternative to the other treatment options of colonoscopic decompression or surgery, when conservative management has failed.     

Traitement de la pseudo-obstruction colique aiguë par néostigmine

Abstract

Acute colonic pseudo-obstruction — that is, massive dilation of the colon without mechanical obstruction — may develop after surgery or severe illness. Although it may resolve with conservative therapy, colonoscopic decompression is sometimes needed to prevent ischemia and perforation of the bowel. Uncontrolled studies have suggested that neostigmine may be an effective treatment.

Methods

We studied 21 patients with acute colonic pseudo-obstruction. All had abdominal distension and radiographic evidence of colonic dilation, with a cecal diameter of at least 10 cm, and had had no response to at least 24 hours of conservative treatment. We randomly assigned 11 to receive 2.0 mg of neostigmine intravenously and 10 to receive intravenous saline. A physician who was unaware of the patients’ treatment assignments recorded clinical response (defined as prompt evacuation of flatus or stool and a reduction in abdominal distention), abdominal circumference and measurements of the colon on radiographs. Patients who had no response to the initial injection were eligible to receive open-label neostigmine three hours later.

Results

Ten of the 11 patients who received neostigmine had prompt colonic decompression, as compared with none of the 10 patients who received placebo (P < 0.001). The median time to response was 4 minutes (range: 3 to 30). Seven patients in the placebo group and the one patient in the neostigmine group without an initial response received open-label neostigmine; all had colonic decompression. Two patients who had an initial response to neostigmine required colonoscopic decompression for recurrence of colonic distention; one eventually underwent subtotal colectomy. Side effects of neostigmine included abdominal pain, excess salivation, and vomiting. Symptomatic bradycardia developed in two patients and was treated with atropine.

Conclusions

In patients with acute colonic pseudoobstruction who have not had a response to conservative therapy, treatment with neostigmine rapidly decompresses the colon.     

Double-blind comparison of two corticosteroid regimens plus mycophenolate mofetil and cyclosporine for prevention of acute renal allograft rejection

BACKGROUND: Renal transplant recipients experience adverse events attributed to corticosteroid therapy. METHODS: This was a multicenter, randomized, double-blind, 6-month, controlled steroid dose-reduction study in renal transplant recipients with an unblinded 6-month follow-up. In the low/stop arm, corticoste. roids were given at half the dosage of control for 3 months from the date of transplantation, and then withdrawn. Both arms received mycophenolate mofetil and cyclosporine. The primary endpoint was the incidence of biopsy-proven acute rejection at 6 months posttransplantation. RESULTS: There were 248 patients in the control group and 252 in the low/stop group. At 6 months the low/stop group had more biopsy-proven acute rejection episodes than the control (23% vs. 14%; P=0.008). At 12 months this increased to 25% vs. 15%. Most rejections were Banff grade I. Twelve-month graft loss was 5% in the low/stop group vs. 4% in the control. At 6 and 12 months serum cholesterol (P<0.01, P<0.01), triglycer. ides (P<0.01, P<0.01), and systolic blood pressure (P<0.001, P<0.001) were lower in the low/stop group. Diastolic pressure was lower (P<0.01) and lumbar spine bone density was greater (P<0.01) in the low/ stop group at 12 months. CONCLUSIONS: In renal transplant recipients treated with mycophenolate mofetil and cyclosporine, reduction and early withdrawal of the prophylactic corticosteroid dose is feasible without an unacceptable increase in serious rejection episodes. This is accompanied by a significant reduction of steroid-related adverse events.     

Pathogenesis and clinical and economic consequences of postoperative ileus

Postoperative ileus is a preventable disease with surprising economic consequences. Understanding the triad of dysmotility in conjunction with an enhanced recovery program improves patient outcome, decreases length of stay in hospital, and lowers the cost. Alvimopan and other investigational promotility medications can help attain these goals. Surgeons should avoid labeling all postoperative abdominal distention as ileus, which not only prevents timely diagnosis and treatment of early postoperative small bowel obstruction or acute colonic pseudo-obstruction but also increases patient morbidity and mortality.     

Multicenter Randomized Prospective Trial of Steroid Withdrawal in Renal Transplant Recipients Receiving Basiliximab, Cyclosporine Microemulsion and Mycophenolate Mofetil

Corticosteroids withdrawal from immunosuppressive regimens has thus far been associated with increased risk of acute rejection episodes. In this study, basiliximab, a chimeric monoclonal interleukin-2 receptor antagonist, added to a maintenance regimen consisting of cyclosporine microemulsion and mycophenolate mofetil was studied for its effectiveness in allowing early corticosteroid withdrawal in de novo renal allograft recipients. Primary renal transplant recipients receiving basiliximab, cyclosporine-microemulsion, and mycophenolate mofetil, were randomized to either corticosteroid withdrawal at day four post-transplantation (n = 40) or standard steroid therapy (n = 43). The primary endpoint was the incidence of biopsy-proven acute rejection episodes. Randomized subjects who underwent transplantation and received at least one dose of basiliximab were analyzed in an intent-to-treat fashion. The incidence of biopsy-proven acute rejection at 12 months was not significantly different between the steroid withdrawal group (20%) and the standard treatment group (16%). Patient and graft survival was 100% in the steroid withdrawal group while one death in a patient with a functioning graft occurred in the standard steroid group. Seventy-two percent of the steroid withdrawal group remained off steroids at 6 months post-transplant. Allograft function and incidence of adverse events and infections were similar between the two groups. Rapid and early corticosteroid withdrawal among renal transplant recipients receiving basiliximab induction and daily therapy with cyclosporine-microemulsion and mycophenolate mofetil was not associated with an increased risk of acute rejection.     

Ogilvie’s syndrome in the surgical patient: A new therapeutic modality

Acute colonic pseudo-obstruction, Ogilvie’s syndrome, most often appears as a complication of other clinical conditions. It is characterized by massive colonic dilation in the absence of a mechanical cause. Therapy for this condition has traditionally been colonoscopic decompression via a flexible colonoscope. We performed a retrospective study to assess the efficacy of Cystografin enema for colonic decompression in Ogilvie’s syndrome. We present a series of 18 patients who developed Ogilvie’s syndrome while hospitalized for trauma (n = 10), burn (n = 1), gastrointestinal surgery (n = 4), and hip replacement (n = 3). The mean pre-enema cecal size was 13 cm (range 10 to 15 cm). The mean postenema cecal size was 8.5 cm (range 6 to 15 cm). Fifteen of the 18 patients underwent Cystografin enema as the primary mode of decompression. Three had undergone prior colonoscopy, which had failed. One of the 18 patients required repeat enema for inadequate decompression after the first enema and one underwent colonoscopy for recurrence. Two patients underwent operative intervention after the enema. There were no complications related to the enema. In all patients we were able to rule out a mechanical cause of large bowel obstruction. We believe the safety, efficacy, and ease of this procedure make Cystografin enema optimal firstline treatment for acute colonic pseudo-obstruction. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998 (poster presentation).     

Acute colonic pseudo-obstruction (Ogilvie's syndrome) after renal transplantation.

BACKGROUND: Acute colonic pseudo-obstruction (Ogilvie's syndrome) in the immunosuppressed patient is associated with increased morbidity and mortality. Renal transplant recipients possess several comorbidities that increase the risk of acute pseudo-obstruction of the colon. The aims of this study were to present our experience with this syndrome and to evaluate the potentiating factors in these patients. A review of the literature for pseudo-obstruction following renal transplantation is presented. METHODS: Seven patients who developed Ogilvie's syndrome were identified in a retrospective review of 550 kidney-only transplants. Pretransplant data, potential risk factors, presentation, management, and outcome details were retrieved. The medical literature was reviewed using Medline. RESULTS: Seventy-eight patients with Ogilvie's syndrome in the early posttransplant period have been reported. The associated morbidity and mortality was heightened in this immunocompromised population. Obese transplant recipients (body mass index >30 kg/m2) were at significantly increased risk for developing this syndrome. CONCLUSION: A broad armamentarium of treatment options is available, but the key to successful resolution lies in early recognition.     

Treatment alternatives in renal failure and renal transplantation patients with nonobstructive colonic dilatation

The incidence of nonobstructive colonic dilatation (NCD) is unknown, but the attendant mortality associated with perforation is nearly 50%. Patients with chronic renal failure and transplant recipients may manifest many of the conditions that have been implicated in the development of NCD. Mechanical obstruction and ischemic bowel disease must be eliminated as causes for colon dilatation. Over a four-year period eight patients (mean age 50 years) were treated for presumed NCD. Six patients with a mean cecal diameter of 12.8 cm were treated initially with colonoscopy. Five patients (83%) had successful endoscopic decompression; of the three remaining patients, one underwent urgent ileocolectomy for cecal ischemia after unsuccessful endoscopic decompression, a second (cecal diameter 13 cm) had a tube cecostomy performed as an initial procedure, and the third (cecal diameter 9 cm) was managed successfully with enemas and nasogastric suction. Two deaths occurred in the series (25%), but both were unrelated to colon distension. No complications of colonoscopy were observed. The sequelae of massive NCD (cecal ischemia, perforation, and protracted sepsis) are poorly tolerated in the immunocompromised patient. Conservative management may be employed in patients with a cecal diameter of 9 cm, but urgent diagnostic and therapeutic colonoscopy is recommended for patients with a cecal diameter of 12 cm or greater. Operative tube cecostomy may be necessary if colonoscopic decompression is unsuccessful or cannot be performed.     

Lymphocyturia: an important diagnostic and prognostic marker in renal allograft rejection

We examined the urine for lymphocytes in 60 renal allograft recipients in the immediate posttransplant period using a simple staining technique with methylene blue. 37 acute rejection episodes associated with deterioration in renal function were observed. Other causes of decreased renal function, such as acute tubular necrosis, vascular occlusion or urologic obstruction were carefully excluded. 34 (92%) of the 37 acute rejection episodes were accompanied by significant lymphocyturia. Lymphocyturia was recognized concomitantly with the rise in serum creatinine in 20 of the 34, whereas in 14 it preceded the rise in serum creatinine by a period of 3.5 +/- 2.5 days. 24 (71%) of the 34 acute rejection episodes were reversed by high dose steroid administration and only 2 of them showed persistent lymphocyturia following treatment. On the other hand, 9 of the 10 nonresponders to steroid therapy showed persistent lymphocyturia. All the nonresponders eventually required maintenance dialysis. Detection of lymphocyturia is not only of value in the diagnosis of acute allograft rejection, but is also useful in determining allograft survival in the immediate posttransplant period.     

Corticosteroid reduction with tacrolimus (CORRETA) TRIAL: a prospective Brazilian multicenter, randomized trial of early corticosteroid reduction versus regular corticosteroid dosage maintenance on a tacrolimus (Prograf) and mycophenolate mofetil (Cellcept) immunosuppression regimen in kidney transplant recipients: interim analysis

Corticosteroids are a cornerstone of immunosuppressive therapy in renal transplantation despite their side effects and morbidity. Newer immunosuppressive agents may be more effective to allow corticosteroid sparing. An interim analysis of 60 completed out of 100 planned primary kidney transplant recipients is presented. All patients on tacrolimus (Prograf) and MMF (Cellcept) were randomized into two groups following a 1:1 distribution for early steroid reduction at posttransplant day 7 (G1; n = 31) versus to long-term maintenance steroids (G2; n = 29). Primary efficacy endpoints were composite endpoint of death, graft loss, or severe acute rejection at 6 and 12 months follow-up. Safety evaluation included severity and frequency of diabetes mellitus, hypertension, hyperlipidemia, leukopenia, infection, malignancy, and severe adverse events. Mean age was 39.1 years, with 45.0% males and 66.7% Caucasians. African-Americans were 25.8% in G1 and 27.6% in G2. One death occurred in each group, as well as one case of severe (Banff III) rejection in G1 (P = 1.00). The incidence of rejection episodes between groups was not significant, namely, 41.9% in G1 and 20.7% in G2 (P = .077). There were no differences between groups concerning mean, systolic and diastolic blood pressure, HbA1c, or creatinine at 12 months. This interim analysis showed no evidence of an increased risk of poorer performance among the early steroid reduction or safety differences in kidney transplant recipients versus a regular dosage steroid group of patients. Further analysis of the complete study data is underway.     

Flow cytometry crossmatching as a predictor of acute rejection in sensitized recipients of cadaveric renal transplants

Flow cytometry crossmatching (FCXM) was developed as a more sensitive assay than the standard complement-dependent cytotoxicity crossmatch (CDCXM) for the detection of anti-donor antibodies, that mediate hyperacute rejection and graft loss in the early post-transplant period in renal transplant recipients. The role of FCXM in predicting long-term clinical outcome in renal allograft recipients is unclear. This study examines the role of FCXM in predicting long-term clinical outcome in highly sensitized recipients of cadaveric renal transplants. All patients (n = 100) with peak panel reactive antibody (PRA) levels > 30%, who received cadaveric renal transplants between 1/1/'90 and 12/31/'95 at our institution, were divided into FCXM + and FCXM - groups. The incidence of acute rejection was determined for each group during the first yr after transplant. Graft survival rates at 1, 2, and 3 yr, and creatinine levels were also compared between groups. FCXM + patients experienced a higher incidence of acute rejection during the first yr after transplant (69 vs. 45%), and a higher percentage of FCXM + patients had more than one episode of acute rejection during the first yr after transplant (34 vs. 8%) when compared to FCXM - patients. There was no statistically significant difference in 1-, 2-, or 3-yr graft survival between FCXM + and FCXM - patients (76 vs. 83, 62 vs. 80, 62 vs. 72%, respectively). These results suggest that sensitized FCXM + cadaveric renal transplant recipients have a higher incidence of acute rejection episodes in the first yr after transplant. Given the association of multiple rejection episodes with poor long-term allograft survival, FCXM may be a useful predictor of long-term clinical outcome in this sub-group of renal transplant recipients.     

Steroid withdrawal in pancreas transplant recipients

BACKGROUND: Numerous studies of steroid withdrawal have been carried out in kidney and liver transplant recipients, but only a few in pancreas transplant recipients. Yet, pancreas transplant recipients could have significant long-term benefits from steroid withdrawal. METHODS: We performed a retrospective analysis to determine the feasibility of steroid withdrawal in pancreas transplant recipients. RESULTS: Of 360 recipients who underwent a pancreas transplant between January 1, 1994 and June 30, 1998, 14 attempted steroid withdrawal (12 simultaneous pancreas-kidney [SPK]; 2 pancreas transplant alone [PTA]). Reasons for steroid withdrawal were bone fractures (n = 3), psychiatric disorders (n = 2), severe acne (n = 1), recurrent infections (n = 4), and problems with hypercholesterolemia or hypertension (n = 4). All 14 were maintained on tacrolimus and mycophenolate mofetil (MMF) immunosuppression, except for 1 who was on tacrolimus and azathioprine (AZA). Of the 14 recipients, 11 had no episodes of acute rejection before steroid withdrawal. The remaining 3 had one or more acute rejection episodes. Of the 14 recipients, 10 (72%) currently remain off steroids (mean follow-up 18 months, range 5-51 months). However, 4 recipients have resumed steroids: 2 after an acute rejection episode (at 2 and 21 months post-withdrawal) and 2 because of leukopenia (WBC < 3000) and an inability to tolerate full-dose MMF. Steroid withdrawal was unsuccessful in both PTA recipients and in 2 of the 12 SPK recipients. All 14 recipients currently have a functioning pancreas graft. However, 1 of the SPK recipients, in whom steroid withdrawal failed, has developed chronic kidney rejection and is now back on hemodialysis awaiting a retransplant. CONCLUSION: Steroid withdrawal is possible in up to 70% of pancreas transplant recipients. Further studies are necessary to define ideal candidates for steroid withdrawal. Based on the results of this analysis, we have launched a prospective, randomized trial of steroid withdrawal in pancreas transplant recipients.     

Ogilvie's syndrome associated with acute cytomegaloviral infection after liver transplantation

Ogilvie's syndrome, or acute colonic pseudo-obstruction, is a rare complication following liver transplantation. We describe two cases in which the onset of Ogilvie's syndrome is strongly temporally associated with acute cytomegaloviral (CMV) infection in immunosuppressed liver transplant recipients. The pseudo-obstruction resolved rapidly in both cases following treatment with intravenous ganciclovir. Acute CMV infection therefore appeared to be causally linked to pathogenesis of Ogilvie's syndrome in these two cases. This association has not been described previously to our knowledge, and should be considered in any transplant patient presenting with Ogilvie's syndrome. Received: 30 July 1998 Revised: 1 August 1999 Accepted: 16 September 1999     

Acute colonic pseudo-obstruction. Current diagnosis and management

Twenty-nine patients with acute colonic pseudo-obstruction were treated over a 6-year period. All had gross abdominal distension which followed either serious systemic illness (23 cases), major surgery (4) or trauma (2). The predominant radiological features were disproportionate segmental or localised dilatation of the caecum and proximal colon, with a relative paucity of distal colonic gas. The correct diagnosis was established and mechanical obstruction excluded in the majority of cases (24) by contrast enema examination. In the remaining 5 cases the diagnosis was made on colonoscopy (4) or at laparotomy (1). Successful colonoscopic decompression was achieved in 2 of 4 cases. Eight patients underwent laparotomy and 3 of 4 patients with caecal perforation and peritonitis died. Two of 21 patients treated conservatively died. Persistence of colonic distension beyond 72 hours, caecal diameter greater than 12 cm or overlying abdominal tenderness indicates urgent decompression. Caecostomy is the advised procedure in patients with non-perforated caecal distension. Prompt recognition and treatment of the condition should eliminate delay in decompression and minimise the risk of caecal perforation.     

Acute colonic pseudo-obstruction (Ogilvie's syndrome) in pneumococcal meningo-encephalitis treated with neostigmine

We report the case of a 71-year-old man with acute colonic pseudo-obstruction that complicates a pneumococcal meningo-encephalitis. After 48 h of conservative management with nothing by mouth, nasogastric suction, fluid and electrolyte correction, withdrawal of any anticholinergic agents, a pharmacological approach with 2 mg of neostigmine was successful in intensive care unit. This treatment was effective in over 80% of patients of recent reports. Neostigmine might be considered as first-line therapy in patients who do not have major contraindications to its use, because of less frequent iatrogenic risk than colonoscopic decompression or surgery.     

Therapeutic colonoscopy in the treatment of colonic pseudo-obstruction

Colonic pseudo-obstruction has been recognized since Ogilvie described this disease in 1948. Metabolic, surgical, and medical causes have been implicated at various times. Treatment has included surgical decompression by cecostomy and colectomy. Successful nonoperative decompression by colonoscopy was first reported by Kukora and Dent in 1977. Since that report several authors have reported their results using this technique. Presented here is a series of nine patients with colonic pseudo-obstruction treated initially with colonoscopy. Patients presented with a variety of associated conditions, including post operative patients, orthopedic injuries, metastatic carcinoma, and an unusual case after a normal vaginal delivery. Eight patients responded well to colonoscopic decompression. One patient, the second in the series, was unable to be decompressed with colonoscopy and underwent a cecostomy under local anesthesia. Successive colonoscopy may be required to allow restoration of normal colonic function, as was the case in seven of our patients. One death occurred, due to unrelated causes. The authors have found colonoscopy to be a safe and reliable therapy for colonic pseudo-obstruction.     

Gastrointestinal complications in renal transplantation

One wonders whether the use of cyclosporin, histamine receptor antagonists, low doses of steroids, and early diagnosis and treatment actually modify the incidence, morbidity, and mortality of gastrointestinal (GI) and pancreatic complications in renal transplantation. To find out, we reviewed 614 kidney transplant recipients between January 1984 and December 1988. One hundred patients (16.2%) were found to have GI and/or pancreatic complications in the following distribution: 9.6% gastroduodenal, 1.3% pancreatic, 4% colonic, and 0.4% small bowel. None of the patients presenting a gastroduodenal ulcer had perforation or bleeding. Fifty-five percent of the patients with this complication had a past history of esogastroduodenal disease, compared to 19.6% in recipients without gastroduodenal complications. Some 4.4% of the patients had a small bowel or a colonic complication and four died of peritonitis due to bowel perforation. Mortality was 35% in those having intestinal resection and/or perforation with peritonitis. Sixteen percent of patients with colonic complications had a known history of diverticula, compared to 3% for those without colonic complications. The incidence of GI and/or pancreatic complications in renal transplant recipients remains high and has caused 1.1% of the deaths in our series. Mortality is essentially due to upper GI bleeding, peritonitis following perforation, and infectious colitis. Better detection of gastroduodenal and colonic disease before transplantation seems to be mandatory. Prevention with histamine H2 receptor antagonists and early surgical treatment of complicated colonic diverticula help to reduce the morbidity and mortality in kidney graft recipients.     

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目的 探讨应用软结肠镜(内镜)对常见下消化道外科疾病的诊治，以提高利用内镜进行诊治的安全性及疗效。方法 回顾1984～2001年37939例行内镜诊治的病人，其中行内镜治疗9039例，包括低位肠梗阻64例、乙状结肠扭转11例、假性结肠梗阻6例、下消化道出血56例、良性肠狭窄23例及肠道息肉8879例。总结操作体会，分析疗效及并发症的原因。结果 低位肠梗阻明确梗阻原因、部位者35例(54．7％，35／64)；乙状结肠扭转复位成功11例(100％，11／11)；假性结肠梗阻经内镜减压，治愈者5例(83．3％，5／6)，急性下消化道出血明确出血原因及部位者37例(66．1％，37／56)，37例中立即经内镜止血成功者36例(97．3％，36／37)；结、直肠吻合口经内镜下扩张均成功(100％，23／23)；内镜下行大肠息肉摘除术8864例，共10105枚，术后出血4例，迟发性穿孔2例；术中经内镜行小肠息肉摘除术15例，共412枚，术后无并发症。结论 内镜提高了下消化道外科疾病的诊治水平，但应严格把握适应证。     

Effect of basiliximab on renal allograft rejection within 1 year after transplantation

Basiliximab is widely used in clinical practice for initial immunosuppressive treatment of renal transplant recipients, seeking to reduce the incidence of acute rejection episodes without adverse events. This retrospective study included 123 renal allograft recipients transplanted at a single center. All were followed for longer than 1 year after transplantation and treated with calcineurin inhibitor and steroid (methylprednisolone) for prophylactic immunosuppression, but basiliximab and mycophenolate mofetil were optional. We compared the outcomes of renal transplant recipients who were versus treated were not with basiliximab as initial immunosuppressive therapy. Basiliximab was used for initial immunosuppression in 42 patients. Their maintenance immunosuppressive treatment included triple (n = 44) or double (n = 79) regimens, including a calcineurin inhibitor (cyclosporine [n = 87] or tacrolimus [n = 36]), methylprednisolone with or without mycophenolate mofetil. Twenty-six (21.1%) patients had a rejection episode within 1 year after transplantation and 22 (17.9%) had infections. Within the first year after transplantation the patients who were treated with basiliximab showed fewer rejection episodes (n = 6, 14.3%) than the patients without this therapy (n = 20, 24.7%), which was not statistically significant (P = .245). However, basiliximab significantly affected the occurrence of rejection episodes among the double immunosuppressive regimen group (P = .006), but not the triple regimen group (P = .098) without an impact on infection episodes (P value of double, triple = .291, .414) within 1 year after transplantation. We concluded that basiliximab was more useful for the recipients treated with double immunosuppression with a calcineurin inhibitor and steroid than for those on a triple regimen including mycophenolate mofetil.