title: Early acute rejection episodes in renal transplantation in relation to immunosuppression protocols: an audit of 100 cases.
abstract: BACKGROUND
  Early acute rejection episodes (ARE) have deleterious effects on graft outcomes. The incidence of ARE in the first 3 months has been reported to be <20%. In a recent audit of ARE among 100 renal transplants, we observed the rates to be high (30%). We retrospectively collected details of donor type, induction therapy, immunosuppression medications, drug levels, HLA mismatches, acute tubular necrosis (ATN), and delayed graft function (DGF) to correlate with ARE and response to therapy.
  
  
  RESULTS
  Thirty rejection episodes occurred after a mean period of 14.3 days after transplantation. Ninety-one patients had induction treatment with either antithymocyte globulin (ATG) or interleukin 2 receptor antibodies (IL2 Rab). The drugs included cyclosporine, mycophenolate, sirolimus, azathioprine, and prednisolone in these patients. There was no significant difference in ARE among the different drug protocols (30.7%-35.2%). Subjects with 4 or more HLA mismatches displayed more ARE (40.3%) compared with those with 3 or less (23%). Subjects with ATN or DGF immediately posttransplantation had a higher incidence of ARE (39.2%) than those without them (26.3%). Deceased donor recipients had a higher episode of ARE (45.1%) compared with live related donor recipients (25%). On stratifying the known risk factors for ARE, subjects with no risk factors had the least (22.2%) ARE compared with those with one (32.5%) or two (47.6%) risk factors. Subjects who failed to achieve adequate cyclosporine (C2) levels showed significantly higher rates of ARE (86.9%) than those with adequate or higher levels (8.6%).
  
  
  CONCLUSIONS
  Higher HLA mismatches, DGF, deceased donor, and failure to achieve adequate cyclosporine levels were observed to be major risk factors for the development of ARE.
authors.affiliation: Hamad Al Essa Organ Transplant Centre, Kuwait University, Safat, Kuwait.
authors.forename: M P
authors.initials: MP
authors.lastname: Nair
authors.forename: M R N
authors.initials: MR
authors.lastname: Nampoory
authors.forename: T
authors.initials: T
authors.lastname: Said
authors.forename: M A
authors.initials: MA
authors.lastname: Halim
authors.forename: M
authors.initials: M
authors.lastname: Mansour
authors.forename: K V
authors.initials: KV
authors.lastname: Johny
authors.forename: M
authors.initials: M
authors.lastname: Samhan
authors.forename: M
authors.initials: M
authors.lastname: Al-Mousawi
mesh_terms: D000208:Acute Disease; D000961:Antilymphocyte Serum / Q000627:therapeutic use; D016572:Cyclosporine / Q000493:pharmacokinetics / Q000627:therapeutic use; D006084:Graft Rejection / Q000453:epidemiology* / Q000276:immunology; D006650:Histocompatibility Testing; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007166:Immunosuppressive Agents / Q000145:classification / Q000627:therapeutic use; D015994:Incidence; D016030:Kidney Transplantation / Q000276:immunology*; D008485:Medical Audit; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D012307:Risk Factors; D020123:Sirolimus / Q000627:therapeutic use; D013997:Time Factors
chemical_list: D000961:Antilymphocyte Serum; D007166:Immunosuppressive Agents; D016572:Cyclosporine; D009173:Mycophenolic Acid; D020123:Sirolimus