Better renal function with enhanced immunosuppression and protocol biopsies after kidney transplantation in children

Abstract

Subclinical rejection may be associated with decreased graft function after renal transplantation (Tx). Detection by protocol biopsies and treatment could thus be important for the long-term prognosis. We have earlier discovered that glomerular filtration rate (GFR) declined in young children during the first 18 months. Consequently, we slightly enhanced and individualized each patient's immunosuppression. This was a retrospective study of 59 pediatric renal Tx patients between 1995 and 2001. The 35 historical controls received triple-therapy of azathioprine, methylprednisolone and cyclosporine. GFR was measured by protocol at discharge, 6 and 18 months, and a core biopsy was obtained at 18 months. The 24 study patients in addition received basiliximab, had GFR measured at 3 and 12 months, and a biopsy taken at 3 months. Based on histology and function, immunosuppression was individually adjusted. The groups were compared for GFR and histology at 18 months after Tx. There were less acute rejection episodes in the study group (0.38 vs. 1.23 per patient) and serum creatinine concentrations were lower. Subclinical rejection was detected and treated in 39% at 3 months. There were more chronic changes in the control (47%) than in the study group (29%) at 18 months. GFR was significantly higher in the study group at 18 months (87 vs. 68 mL/min/1.73 m(2)), most remarkably in patients < or =2 yr of age (99 vs. 68 mL/min/1.73 m(2)). Detection of subclinical rejection and slightly enhanced and individualized immunosuppression improved GFR 18 months after renal Tx, especially in the youngest patients.

Chronic allograft nephropathy

“…Untreated SCR can lead to the development of overt ACR with graft dysfunction or may smoulder on to eventual CAN. The incidence of subclinical inflammatory infiltrates of 35–53% [18, 42] in protocol biopsies at 3 months post paediatric kidney transplants are similar to adult reports [11], and both groups of patients show reduction in SCR rates by 12–18 months [11, 42]. …”

Surveillance renal transplant biopsies and subclinical rejection at three months post‐transplant in pediatric recipients

“…While the progression of SCR to CAN and late graft failure has been reported (7, 15), others did not find SCR to be a precursor to late graft loss (10, 11). In pediatric transplants, experiences with surveillance biopsies are limited to few studies (14, 15). Therefore, the incidence, predisposing factors, and clinical outcomes of SCR are not well defined in children.…”

The Utility of 1- and 3-Month Protocol Biopsies on Renal Allograft Function: A Randomized Controlled Study

“…In addition to allowing detection and treatment of histological abnormalities such as SCR and dose adjustments for potentially nephrotoxic CNIs, protocol biopsy findings might lead to other subtle changes in local management practices that contribute to preservation of GFR. Seikku et al (35) commented on the value of tailoring of immunosuppressive therapy on the basis of findings from protocol biopsies.…”