Kidney allograft rejection: Diagnosis and treatment practices in USA‐ A UNOS survey

Abstract

Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD). While the short-term graft survival has improved with time, the long-term graft survival remains largely unchanged. 1,2 Immunological graft injury from acute and chronic rejection constitutes a major cause of graft loss post kidney transplantation. 3,4 The ideal management strategy to counter immunological graft injury is to diagnose accurately and treat adequately. To diagnose a rejection accurately, the Banff diagnostic classification has evolved over the last decade to incorporate new molecular tools and gene array techniques on blood and tissue specimens. 5 Use of these new techniques have resulted in identification of several new phenotypes of graft injury, for both T-cell-mediated (TCMR) and antibody-mediated rejection (ABMR) (eg C4D ± ABMR). 5 In addition, there are several novel detection methods for graft injury that have not yet been formally inducted in the official Banff classification, but are nevertheless, available

Effectiveness of T cell–mediated rejection therapy: A systematic review and meta-analysis

“…Anti‐rejection therapy is foundational to transplant management and standard‐of‐care for TCMR is considered pulse steroids, but significant practice heterogeneity exists with respect to dose, duration, taper, decision to use thymoglobulin, and inconsistent treatment of Banff Borderline rejection. 11 , 12 , 14 Such center‐specific practices reflect the lack of robust RCTs to support evidence‐based recommendations, 47 , 48 , 49 as well as equipoise with respect to pulse steroid regimens from a clinical trials perspective. High quality observational data for anti‐rejection therapy in patients on Tac/MPA‐based therapy are also limited.…”

“…Evaluating histological outcomes after early TCMR therapy is critical to defining the rates of remission and overall therapeutic effectiveness. While 60%–70% of clinicians rely on graft functional markers to define BPAR resolution, 11 , 12 serum creatinine is very insensitive with only an AUC 0.59 for detecting BPAR. 13 There is a dearth of evidence evaluating histologic persistence of BPAR after anti‐rejection therapy for TCMR.…”

High PIRCHE Scores May Allow Risk Stratification of Borderline Rejection in Kidney Transplant Recipients

“…However, the response to therapy is sometimes inconsistent even in clinically significant TCMR (27), and consensus guidelines regarding treatment for BLR are lacking. The results of commonly accepted treatment strategies have been shown in the recent comprehensive UNOS survey from kidney transplant programs in the USA (28). The challenge to balance adequate therapy to prevent allosensitization while avoiding over-immunosuppression often places clinicians at difficult management decisions.…”

Revisiting acute T cell–mediated rejection in kidney allografts

“…Although data on the treatment of TCMR were not available in this study, common practice is that TCMR events are treated with high-dose steroids, 4 despite little evidence from the current era. Surprisingly little is known about the histological response of TCMR to treatment, as only a few studies have included follow-up biopsies after treatment.…”