Spectrum of Acute Rejections and Short Term Outcome After Kidney Transplantation

Spectrum of acute rejections and short term outcome after kidney
transplantation
Manoj Singhal, Anuja Porwal , Varun Verma, Alok Gupta, Jai Inder Singh
BACKGROUND
Acute rejection after transplant is associated with significant reduction in graft survival. With
advent of newer immunosuppressants and induction agents the incidence of acute rejection has
decreased worldwide, however antibody mediated rejections pose a continued challenge for short
and long term graft survival. We have analyzed spectrum of acute rejections episodes within 1
year of kidney transplantation. We also analyzed Patient and allograft survival at 1 year and at
end of the study.
MATERIAL AND METHOD
In a single center, bidirectional observational study, we analyzed 140 consecutive patients
transplanted from May 2012 to May 2014. 11 patients were excluded (5 deceased donor,3 second
transplant, 2 combined liver & kidney transplant and 1 patient <18yrs age). 9 patients were lost
to follow up, 8 were lost after 1 month of follow up and 1 after 14 days post transplant. All
patients were offered induction therapy based on their socioeconomic status, risk of
immunological injury and infections. Patients who were at a higher risk of immunological injury
received high dose rATG (>= 4.5mg/kg) and all other patients received either low dose ATG (<
4.5 mg /kg; usually 3 mg/kg), Basiliximab (20mg on D0 & D4) or no induction. Only 5 patients
received high dose ATG, these were not included in final analysis due their insignificant number,
however among these 3patients had second transplant. Total 118 patients were analysed. All the
patients received triple immunosuppressant protocol consisting of Tacrolimus, Mycophenolate
Mofetil and Steroids. Trough levels of tacrolimus were targeted at 8-12 ng/ml for the first 2
months, 6-8 ng/ml from 2 to 6 months and 4-6 ng/ml thereafter.
RESULTS
Of 118 recipients, 103 (88%) were men. The mean age of recipients was 37.8 10.6SD years
(range 18 62 years) the mean age of the donors was 43.6 10.6SD years (range 22 72 yrs.).
The mean follow up period was 1.44 years (range 1-3yrs). 58 patients had no induction,22 patients
had Basiliximab induction, 47 patients received low dose ATG induction. Total 27 (22.88%.) BPAR
occurred in the 118 patients analyzed, 19 (70%) were AMR, 6 (22%) were ACR and 2 (8%) were
mixed rejections. Incidence was 17(29%)(11AMR+4ACR+2Mixed) in no induction recipients, 4
(18%)(3AMR+1ACR) in Basiliximab recipients and 6 (12%)(4AMR+2ACR) in low dose ATG
recipients; difference was statistically significant in no induction vs low dose ATG group (p=
0.050). 23 (85%) rejections occurred within one month post-transplant,16(94%) in no induction
recipients,4(100%) in Basiliximab and 3(50%) low dose ATG recipients; difference was
statistically significant in no induction vs low dose ATG group (p= 0.040). 3 rejections occurred
within 1-6 months post- transplant and 1 after 6 month.
AMR was treated with steroid, PLEX & low dose IvIg (1gm/kg), Rituximab /Bortezomib was
given as per requirement for refractory AMR.ACR was treated with Steroid and + ATG. Out of
the 16 early rejections in no induction recipient, 5(31.2%) (2 AMR+3ACR) patients had
complete recovery of renal function with treatment, 7(43.7%) (4AMR + 2 Mixed+ 1 ACR) had
partial recovery and 4 (25%)(4AMR) grafts were lost. Among basiliximab induction recipient
out of the 4(28.5%) rejections 2(50%)(1AMR+1ACR) had complete recovery, 1(25%)AMR had
partial recovery and 1(25%) (AMR) graft was lost, in low dose ATG recipients 6 rejections,
2(40%) (ACR+AMR) had complete recovery, 4(60%) (3AMR+1ACR) had partial recovery and
no graft was lost.
A total of 13(10%) grafts were lost during the follow up period due to various causes. There were
6 deaths and 6 grafts were lost during follow up. Out of 7 deaths 3 due to infection acquired
immediately after an episode of acute rejection and 1due to severe sepsis 1due to FHF,1
mesenteric ischemia and1 hemorrhagic shock. 3 grafts were lost due to chronic AMR , 1vascular
thrombosis & graft rupture, 1fungal sepsis after severe AMR and 1 due to recurrent UTI
&pyelonephritis. Overall Graft survival, death censored graft survival and patient survival at the
end of one year is 105 (88.9%) ,110(93%) and 112(94.9%).
Conclusion
Overall rejection rate is 22.88%. in live related kidney transplant recipients. AMR remains an
important cause of acute rejection and graft loss in the early post- transplant period. Acute
rejections are less frequent after 6 months post-transplant.
There was no significant difference in response to treatment of rejection with rATG induction,
however no induction group had more severe degree of early rejections and early graft loss.

Spectrum of Acute Rejections and Short Term Outcome After Kidney Transplantation

Uploaded by

Copyright:

Available Formats

Spectrum of Acute Rejections and Short Term Outcome After Kidney Transplantation

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Spectrum of Acute Rejections and Short Term Outcome After Kidney Transplantation

Uploaded by

Copyright:

Available Formats

Spectrum of acute rejections and short term outcome after kidney

You might also like