Factors Associated With Graft Rejection in the Cornea Preservation Time Study

Abstract

Purpose: To identify factors related to graft rejection following Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). Design: Cohort study within a multicenter randomized clinical trial. Methods: 1330 eyes of 1090 subjects undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0–7 days (N=675) or 8–14 days (N=655) and followed for three years. Central endothelial cell density (ECD) was determined by a central image analysis reading center. Multivariable Cox models adjusted for PT, recipient diagnosis, and surgeon effect were used to identify factors associated with rejection. Results: Cumulative probability of definite graft rejection was 3.6% (99% CI 2.5% to 5.3%). Younger recipient age was associated with graft rejection [p<0.001; HR: 0.53 (0.33, 0.83) per decade]. PT, donor-recipient gender mismatch, recipient diagnosis, recipient race, graft size, discontinuation of topical corticosteroids, and immune-modulators, prior immunizations within three months, and prior glaucoma surgery were not associated with rejection (p>0.01). Among clear grafts with an ECD measurement at baseline and 3 years (N=913), endothelial cell loss (ECL) was greater in eyes that experienced a rejection episode (N=27) than in those that did not (N=886) (48% vs 38%, p=0.03). Twelve of 44 eyes (27%) with definite graft rejection subsequently failed, comprising 15% of the 79 failures in the CPTS. Conclusions: Graft rejection is uncommon after DSAEK and more likely with younger age, in a study cohort mostly > 50 years old. Rejection increases ECL, but it is not a leading cause of DSAEK failure.

Donor and Recipient Sex Matching and Corneal Graft Failure in High-Risk and Non-High-Risk Patients

“…A large national cohort study conducted by the National Health Service (NHS) Blood and Transplant in the UK showed that sex mismatched corneas were at a greater risk for failure, regardless of diagnosis or surgery type [ 8 ]. However, two recent studies from the US reported that donor-recipient sex combinations did not affect rejection episodes or graft survival [ 11 , 12 ].…”

Evaluation of Donor and Recipient Characteristics Involved in Descemet Stripping Automated Endothelial Keratoplasty Outcomes

“…In this study, partial graft dislocation was the most frequent complication observed (22 eyes) and has been always managed by early rebubbling. (8,(16)(17)(18)(19)(20). These multicentre, randomized trials evaluated the incidence of several factors on graft failure.…”

An endothelial rejection line following Descemet stripping automated endothelial keratoplasty

“…A similar observation was reported by Sepsakos et al [ 4 ], as termination of steroid use was found to be the strongest risk factor for graft rejection. However, a more recent study did not find topical corticosteroid termination to be a significant factor predisposing to endothelial rejection after DSAEK [ 5 ]. In addition, close follow-up, especially in the first postoperative year, and subsequent long-term follow-up have been found by Wu et al to be the most important factor in varying immunologic graft rejection rates [ 1 ].…”

“…Signs of endothelial graft rejection include keratic precipitates (KPs), corneal oedema and an anterior chamber reaction. According to different studies on Descemet stripping automated endothelial keratoplasty (DSAEK) complications, the 3-year incidence of immunologic graft rejection episodes ranges from 4 to 22% [1][2][3][4][5]. A recent study by Price et al found that endothelial rejection occurs in 7.9% of DSAEK cases over a 5-year period [6].…”