Individualization of maintenance immunosuppressive therapy equalizes acute rejection risk in African American versus non–African American renal allograft recipients

Polyomavirus allograft nephropathy (PVAN) has a negative impact on allograft function and survival. Analysis of paired kidneys from same donor can help to understand the role of recipient risk factors for PVAN. This analysis can also define donor related risk factors. Purpose: To identify recipient related risk factors for PVAN. Patients and Methods: Transversal cohort of 24 renal transplant patients in regular outpatient clinic follow up. Twelve patients with PVAN and their paired controls (recipients from same donor) without decoy cells in cytology were included in this analysis. Medical records were analyzed for demographic data, information of transplant and post-transplant data (acute rejection, renal function, immunosuppression). Results: Groups were comparable for initial immunosuppressive therapy based on basiliximab induction, tacrolimus, mycophenolate and steroids. Etiology of end-stage renal disease, race, age, HLA matching and delayed graft function considered as risk factors were also similar between patients with or without PVAN. However, PVAN group had more male patients (91.6 vs. 66.6%, PVAN versus control, p<0.05), higher incidence of biopsy proven acute rejection (41.6% vs. 8.3%, PVAN vs. control, p<0.05) and a trend to shorter cold ischemia time (15.6+6.2 versus 19.7+5.0, p=0.06). Conclusion: In this series, there were no significant differences in immunosuppressive therapy, age and HLA matching between patients with or without PVAN common risk factors. The only factors to be considered in this series were older age and a trend to shorter cold ischemia time in PVAN patients.

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The Relationship of Untreated Borderline Infiltrates by the Banff Criteria to Acute Rejection in Renal Allograft Biopsies

Journal of the American Society of Nephrology ◽

10.1681/asn.v1081806 ◽

1999 ◽

Vol 10 (8) ◽

pp. 1806-1814

Author(s):

SHANE M. MEEHAN ◽

CHRISTOPHER T. SIEGEL ◽

ANDREW J. ARONSON ◽

SHARON M. BARTOSH ◽

J. RICHARD THISTLETHWAITE ◽

...

Keyword(s):

Acute Rejection ◽

Serum Creatinine ◽

Renal Allograft ◽

Tubular Necrosis ◽

Maintenance Immunosuppression ◽

Initial Biopsy ◽

Elevated Creatinine ◽

Relationship Of ◽

The Relationship

Abstract. The relationship of borderline infiltrates to acute rejection by Banff criteria in renal allografts of patients receiving only maintenance immunosuppression is not clear. Renal allograft biopsies with borderline lesions that were not treated with additional anti-rejection therapy were retrospectively studied. Sixty-five such biopsies were identified from 50 patients, and their outcome was determined by serum creatinine and/or histologic findings in subsequent biopsies, up to 40 d after the initial biopsy. In addition to the borderline infiltrates, there was evidence of acute cyclosporine or tacrolimus toxicity (58%), acute tubular necrosis (12%), and urinary obstruction (12%). Forty-day follow-up after 30 (46%) biopsies revealed serum creatinine <110% of baseline, and repeat biopsies were not indicated. In 17 (26%), the serum creatinine initially decreased, then increased, and follow-up biopsies showed acute rejection in nine. In 18 (28%), the creatinine remained elevated and follow-up biopsies revealed acute rejection in nine. The untreated borderline infiltrates were thus nonprogressive after 47 biopsies (72%) and progressed to histologic acute rejection after 18 (28%). When there was increasing or persistently elevated creatinine after the initial biopsy, 51% of cases (18 of 35) progressed to acute rejection. Infiltrates that progressed to rejection had more frequent glomerulitis (7 of 18 versus 3 of 47, P = 0.003) and Banff acute score indices (i+t+v+g) >2 (16 of 18 versus 29 of 47, P = 0.03). A majority (72%) of borderline infiltrates not given additional anti-rejection therapy did not progress to acute rejection over 40 d of follow-up, suggesting that conservative management of these lesions, at least in the short term, may be more appropriate than routine treatment as acute rejection.

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