title: The utility of 6-month protocol renal biopsy under modern immunosuppression.
abstract: BACKGROUND
  Protocol biopsies after renal transplantation are useful in detecting subclinical rejection. In earlier studies, the incidence of subclinical rejection was high among renal transplant recipients on a cyclosporine-based immunosuppression. However, recent data show that subclinical rejection is low under tacrolimus-based immunosuppression. This study evaluates the utility of 6-month protocol biopsy in renal transplant recipients under induction with rabbit antithymocyte globulin and maintenance immunosuppression with tacrolimus, mycophenolate mofetil (MMF) and corticosteroids.
  
  
  METHODS
  6-month protocol biopsies on 40 transplant recipients were analyzed for borderline and subclinical rejections. Allograft injury at biopsy was evaluated using the chronic allograft damage index score system (CADI) and was compared with initial scores obtained at implantation.
  
  
  RESULTS
  Borderline rejection was detected in 1 out of 40 patients. No case of subclinical rejection was detected at protocol biopsy. In 31 patients with corresponding implantation biopsies, mean CADI score increased from 1.1 +/- 1.4 to 2.8 +/- 2.1 at 6 months despite stable graft function. In the subgroup of patients with a 6-month CADI score of 2 or less (n = 11), graft function remained stable at 12 months post transplant (65.3 +/- 16.9 ml/min/1.73 m2 at 6 months vs. 65.2 +/- 16.7 ml/min/1.73 m2 at 12 months, p = 0.96). In contrast, allograft function declined significantly at 12 months in those with a 6-month CADI score of > 2 (n = 20) (64.3 +/- 13.5 ml/min/1.73 m2 at 6 months vs. 51 +/- 9.8 ml/min/1.73 m2 at 12 months, p = 0.0006).
  
  
  CONCLUSIONS
  While the incidence of borderline and subclinical is low under antilymphocyte antibody induction and tacrolimus-based immunosuppression, chronic allograft damage is highly prevalent at 6 months post transplantation. Our findings suggest that protocol biopsies under current immunosuppression may be more useful in the early detection of chronic allograft nephropathy (CAN).
authors.affiliation: Division of Hypertension and Renal Diseases, Rhode Island Hospital, Brown University School of Medicine, Providence, RI 02903, USA. ayango@lifespan.org
authors.forename: A
authors.initials: A
authors.lastname: Yango
authors.forename: R
authors.initials: R
authors.lastname: Gohh
authors.forename: L J
authors.initials: LJ
authors.lastname: Wang
authors.forename: P
authors.initials: P
authors.lastname: Morrissey
authors.forename: M
authors.initials: M
authors.lastname: Shih
authors.forename: K
authors.initials: K
authors.lastname: Lowery
authors.forename: K
authors.initials: K
authors.lastname: Charpentier
authors.forename: A
authors.initials: A
authors.lastname: Gautam
authors.forename: C
authors.initials: C
authors.lastname: Mendonca
authors.forename: S
authors.initials: S
authors.lastname: Kumar
authors.forename: L
authors.initials: L
authors.lastname: Dworkin
authors.forename: A
authors.initials: A
authors.lastname: Monaco
mesh_terms: D001706:Biopsy / Q000706:statistics & numerical data*; D002908:Chronic Disease; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology / Q000276:immunology / Q000473:pathology*; D006085:Graft Survival; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D015994:Incidence; D007668:Kidney / Q000473:pathology*; D016030:Kidney Transplantation / Q000276:immunology / Q000473:pathology*; D008297:Male; D015995:Prevalence; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D014184:Transplantation, Homologous; D014481:United States / Q000453:epidemiology
chemical_list: D007166:Immunosuppressive Agents