title: Completely reversed acute rejection is not a significant risk factor for the development of chronic rejection in renal allograft recipients.
abstract: Although acute rejection (AR) has been shown to correlate with decreased long-term renal allograft survival, we have noted AR in recipients who subsequently had stable function for more than 5 years. We reviewed 109 renal graft recipients with a minimum of 1 year graft survival and follow-up of 5-8 years. Post-transplant sodium iothalamate clearances (IoCI) measured at 3 months and yearly thereafter were used to separate recipients into 2 groups. In 61 patients (stable group), there was no significant decrease ( > 20 % reduction in IoCl over 2 consecutive years) in IoCl. Forty-eight patients had significant declines in IoCl (decline group). Groups were compared for incidence, severity, timing, and completeness of reversal of AR. Rejection was considered completely reversed if the post-AR serum creatinine (Scr) returned to or below the pre-AR nadir Scr after anti-rejection therapy. The incidence of AR was not significantly different between groups (47% vs 52%). A trend toward a lower mean number of AR episodes per patient was noted in the stable group (0.69 vs 1.04, P = 0.096), but the timing of AR was not different. Steroid-resistant AR occurred in approximately 25 % of both groups. A striking difference was seen in complete reversal of AR, with the stable group having 100% (42/42 episodes of AR in 29 patients) complete reversal whereas only 32 % (8/25) of the patients in the decline group had complete reversal (P < < 0.001). Of 8 declining patients with complete reversal, graft loss was due to chronic rejection (CR) in only 3. Seventeen declining patients had incomplete reversal of AR, and 82 % (14/17) lost their grafts to CR. Overall, only 8% (3/37) of the recipients with complete reversal of AR developed CR. No patients with incompletely reversed AR had stable long-term function as measured by IoCl. AR is not invariably deleterious to long-term renal graft function if each episode of AR can be completely reversed.
authors.affiliation: Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA 01199, USA.
authors.forename: R L
authors.initials: RL
authors.lastname: Madden
authors.forename: J G
authors.initials: JG
authors.lastname: Mulhern
authors.forename: B J
authors.initials: BJ
authors.lastname: Benedetto
authors.forename: M H
authors.initials: MH
authors.lastname: O'Shea
authors.forename: M J
authors.initials: MJ
authors.lastname: Germain
authors.forename: G L
authors.initials: GL
authors.lastname: Braden
authors.forename: J
authors.initials: J
authors.lastname: O'Shaughnessy
authors.forename: G S
authors.initials: GS
authors.lastname: Lipkowitz
mesh_terms: D000208:Acute Disease; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000368:Aged; D001379:Azathioprine / Q000627:therapeutic use; D002908:Chronic Disease; D016572:Cyclosporine / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D006084:Graft Rejection / Q000188:drug therapy* / Q000453:epidemiology* / Q000503:physiopathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016030:Kidney Transplantation / Q000502:physiology* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016853:Muromonab-CD3 / Q000627:therapeutic use; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D014184:Transplantation, Homologous
chemical_list: D000305:Adrenal Cortex Hormones; D007166:Immunosuppressive Agents; D016853:Muromonab-CD3; D016572:Cyclosporine; D001379:Azathioprine