Risk Factors for Steroid-Resistant T-Cell–Mediated Acute Cellular Rejection and Their Effect on Kidney Graft and Patient Outcome

Abstract

Objectives: Acute rejection in renal transplant is considered a risk factor for short-term and long-term allograft survival. The expected reversal rate for the first acute cellular rejection, by steroid pulse, ranges between 60% and 100%, and lack of improvement within 1 week of treatment is defined as steroidresistant rejection. This work sought to evaluate factors that lead to steroid-resistant acute cellular rejection among patients with first live-donor renal allotransplant and its effect on graft and patient survival. Materials and Methods:Patients with an improvement in serum creatinine levels were considered controls (group 1; n=100); while the others were considered an early steroid-resistant group (group 2; n=99). Both groups were matched demographically. Results: Patients with a target cyclosporine level below accepted therapeutic levels were significantly higher in group 2 (P = .02). We found no significant differences between the groups regarding posttransplant complications (P > .05). Mean hospital stay was longer in group 2 (P = .021). Living patients with functioning graft were more prevalent in group 1, while those alive on dialysis were more prevalent in group 2. The groups were comparable regarding long-term patient and graft survival despite significantly lower creatinine values in patients of group 1 at 6 months' follow-up (P ≤ .001).Conclusions: Prebiopsy low cyclosporine trough levels and associated chronic changes among patients who were maintained on calcineurin inhibitor-based regimens represented the most-important risk factors for the early steroid-resistant group. Rescue therapies improve short-term graft outcome; however, they did not affect either patient or long-term graft survival after 5 years' follow-up.

Difficult-to-Treat Rejections in Kidney Transplant Recipients: Our Experience with Everolimus-Based Quadruple Maintenance Therapy

“…In a previous study that classified all rejections according to Banff 2013 classification, the graft survival at 21 months after biopsy-proven diagnosis of any TCMR, where probably both acute and chronic TCMR were grouped together, was reported to be 54%, which appears to be significantly worse than the 90% found in our study for caTCMR alone at five years [33]. Pertaining to steroidresistant aTCMR, the 5-year graft survival rate of 67% observed in our study is slightly lower than the 70-80% reported in several past studies where thymoglobulin was used for steroid-resistant rejections [34][35][36]. However, the majority (63%) of our aTCMR patients included here had a contraindication for the use of thymoglobulin, which may explain the slightly lower rates observed in our study.…”