title: Late and early C4d-positive acute rejection: different clinico-histopathological subentities in renal transplantation.
abstract: This study was performed to investigate the clinical and pathologic features of C4d-positive steroid-resistant acute rejection (AR) at different phases after renal transplantation. Fifty-six kidney allograft recipients with C4d-positive AR were divided into three groups, very early rejection (VER, occurring < or =14 days following transplantation, n=28), early rejection (ER, occurring 15-180 days following transplantation, n=5), and late rejection (LR, occurring >180 days following transplantation, n=23). Clinical and pathological features were evaluated. Significantly more patients in the ER and LR groups were associated with a reduction or withdrawal of immunosuppressants. More patients in the ER and LR groups experienced a significant (>3 g/l) decrease in serum albumin (80% ER, 91.3% LR, 7.1% VER, P<0.001) and a decrease in hemoglobin (>1 g/dl) (80, 100 vs 17.9%, P<0.001). Most VER patients reported a fever and had very rapid graft dysfunction requiring dialysis. Significantly more patients (87%) had interstitial fibrosis and tubular atrophy in the LR group compared with the other groups and 13% had transplant glomerulopathy. Most cases of VER were reversed with tacrolimus and mycophenolate mofetil treatment, with or without immunoadsorption, with a 1-year survival rate of 96.4%, compared with only 60 and 52.2% in the ER and LR groups. In conclusion, C4d-positive steroid-resistant AR at different time points is associated with unique clinico-histopathological manifestations requiring distinct treatment strategies. Late episodes are usually associated with significantly reduced serum albumin and hemoglobin levels and a poorer outcome. A more specialized treatment protocol should be established for these patients.
authors.affiliation: Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.
authors.forename: Q
authors.initials: Q
authors.lastname: Sun
authors.forename: Z-H
authors.initials: ZH
authors.lastname: Liu
authors.forename: S
authors.initials: S
authors.lastname: Ji
authors.forename: J
authors.initials: J
authors.lastname: Chen
authors.forename: Z
authors.initials: Z
authors.lastname: Tang
authors.forename: C
authors.initials: C
authors.lastname: Zeng
authors.forename: C
authors.initials: C
authors.lastname: Zheng
authors.forename: L-S
authors.initials: LS
authors.lastname: Li
mesh_terms: D000208:Acute Disease; D000328:Adult; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology*; D005260:Female; D006084:Graft Rejection / Q000188:drug therapy / Q000276:immunology* / Q000473:pathology*; D006085:Graft Survival / Q000276:immunology; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D011183:Postoperative Complications / Q000188:drug therapy / Q000276:immunology / Q000473:pathology; D012709:Serum Albumin / Q000378:metabolism; D016559:Tacrolimus / Q000627:therapeutic use; D013997:Time Factors
chemical_list: D006454:Hemoglobins; D007166:Immunosuppressive Agents; D012709:Serum Albumin; D009173:Mycophenolic Acid; D016559:Tacrolimus