Impact of Acute Rejection on Kidney Allograft Outcomes in Recipients on Rapid Steroid Withdrawal

Abstract

Background. Our aim was to study the impact of clinical acute rejection (CR) and subclinical rejection (SR) on outcomes in kidney transplant recipients treated with rapid steroid withdrawal (RSW). Methods. All patients who received a living or deceased donor kidney transplant and were treated with RSW were included. The primary outcome was death-censored graft survival. Biopsies with Banff borderline changes were included with the rejection groups. Results. 457 kidney transplant recipients treated with RSW were included; 46 (10%) experienced SR, and 36 (7.8%) had CR. Mean HLA mismatch was significantly higher in the CR group. The Banff grade of rejection was higher in the CR group. There was a larger proportion of patients in both rejection groups with the combination of IFTA and persistent inflammation on the follow-up protocol biopsy done at 1 year. The estimated 5-year death-censored graft survival was 81% in SR, 78% in CR, and 97% in the control group (P < .0001). Significant differences were observed in allograft survival between the CR and control group (HR 9.06, 95% CI 3.39–24.2) and between the SR and control group (HR 4.22, 95% CI 1.30–13.7). Conclusion. Both SR and CR are associated with an inferior graft survival in recipients on RSW.

The clinical and pathological significance of borderline T cell–mediated rejection

“…Palomar reported that untreated BL-R often failed to recover to baseline. 22 Immune-mediated tubular damage was commonly observed at the time of BL-R index biopsy, 19,20,[23][24][25][26] within 40 days, 18 echoing other studies. 9,11,12,26,28,29 We found that…”

“…26,30,31 One sobering result was the poor performance of conventional anti-T cell therapy involving pulse corticosteroids to promptly control BL-R (and A-TCMR). Interstitial inflammation persisted after 9,17,19,20,23,25,26 Schweitzer found that inflammation was un- Subclinical BL-R detected by protocol biopsy is a more problematic entity, and contrary to assumption, was not entirely benign:…”

“…A-TCMR, acute T cell-mediated rejection; BL-R, borderline TCMR moderate IF/TA in 34% (52.9% for A-TCMR) 23. Actuarial survival curves demonstrate reduced deathcensored graft survival for BL-R and A-TCMR diagnostic categories of T cell rejection (vs NIL, n = 428 unique biopsies, top panel).…”

Impact of low‐level BK polyomavirus viremia on intermediate‐term renal allograft function

“…In addition, it must be mentioned that in patients with high‐level viremia, the eGFR was already inferior 3 months after transplantation and rejection episodes were more frequent compared with the other groups. In the context of eGFR and graft rejection as a predictor of graft outcome and eGFR decline, this could mean that these grafts were already compromised or impaired by rejection early after transplantation, which is a limitation of this study.…”

Minimizationvstailoring: Where do we stand with personalized immunosuppression during renal transplantation in 2015?

“…A retrospective study conducted in the United States on re-transplant patients receiving rabbit-derived antithymocyte globulin (rATG) induction therapy [15] showed relatively low rates of acute rejections in both the steroid withdrawal and triple therapy groups. While these and other studies tend to show non-inferiority of steroidfree maintenance regimens in low risk patients -and perhaps a hint that in higher risk patients receiving induction therapy early withdrawal may be safe -it remains unclear whether the improvements in metabolic complications, including new onset diabetes [16] , skeletal complications including fracture risk [17] are sufficiently counterbalancing the risk for long-term immunological [18] and increased rates for DSA [19] in this setting. On the other hand, the possibility of increased risk for antibody-mediated rejection after steroid withdrawal in high-risk populations is currently not sufficiently explored.…”