Pretransplant identification of acute rejection risk following kidney transplantation

Abstract

SummaryLack of an accepted definition for 'high immunological risk' hampers individualization of immunosuppressive therapy after kidney transplantation. For recipientrelated risk factors for acute rejection, the most compelling evidence points to younger age and African American ethnicity. Recipient gender, body mass, previous transplantation, and concomitant infection or disease do not appear to be influential. Deceased donation now has only a minor effect on rejection risk, but older donor age remains a significant predictor. Conventional immunological markers (human leukocyte antigen [HLA] mismatching, pretransplant anti-HLA alloantibodies, and panel reactive antibodies) are being reassessed in light of growing understanding about the role of donor-specific antibodies (DSA). At the time of transplant, delayed graft function is one of the most clear-cut risk factors for acute rejection. Extended cold ischemia time (≥24 h) may also play a contributory role. While it is not yet possible to establish conclusively the relative contribution of different risk factors for acute rejection after kidney transplantation, the available data point to variables that should be taken into account at the time of transplant. Together, these offer a realistic basis for planning an appropriate immunosuppression regimen in individual patients.

Impact of pre-transplant antiaggregant and anticoagulant therapies on early hemorrhagic and cardiovascular events after kidney transplantation

“…The correlation between blood transfusions and acute rejection has been long debated and there are studies showing no association [21] and studies showing a higher human leukocyte antigen (HLA) sensitization in transfused patients [22]. This correlation was not an endpoint of our study and it was not studied in detail, so this result should be taken with the appropriate caution: indeed, there may be several confounders, including a higher DGF rate in transfused patients, which is a well-known risk factor for acute rejection [23]. Moreover, patients with early graft loss or who developed an early acute rejection are expected to need more blood transfusions, as their renal function and response to erythropoietin are suboptimal: therefore, such patients have been frequently excluded from studies aimed to evaluate the correlation between transfusions and rejection [21].…”

Cytolytic Induction Therapy Improves Clinical Outcomes in African-American Kidney Transplant Recipients

“…As this was a retrospective cohort analysis, choice of induction therapy was not random or controlled and there were significant baseline differences between those who received cytolytic versus IL-2RA induction therapies; the cytolytic group had substantially more risk factors for acute rejection and graft loss, when compared with the IL-2RA group. 47 We attempted to account for this through adjustment in multivariable models, but there is likely residual confounding and unmeasured risk that was not accounted for in these models. 50 However, these would likely lead to bias toward the null and thus the estimates from this analysis are conservative.…”

Peritransplant Soluble CD30 as a Risk Factor for Slow Kidney Allograft Function, Early Acute Rejection, Worse Long-Term Allograft Function, and Patients’ Survival

“…The decrease of sCD30 after transplant in our study was absent or was less significant in females, especially in those with pregnancies in anamnesis, in the recipients of the kidney from older donors, and in recipients of living-donor graft. As highlighted by several studies [39, 46, 47], all these factors might provoke sensitization and, consequently, higher incidence of AR. In addition, we found a link between previous pregnancies and AR, as well as between previous transplants and worse function at 3 years, which confirm negative consequences of presensitization in our patients' cohort.…”