title: Increase in proteinuria >200 mg/g after late rejection is associated with poor graft survival.
abstract: BACKGROUND
  There is no information on the effects of proteinuria on outcomes following rejection.
  
  
  METHODS
  We addressed this question in a retrospective study of 925 kidney transplant recipients between January 2003 and December 2007. Selection criteria were based on (i) biopsy proven diagnosis of a first episode of acute rejection, and (ii) available data on urine protein to creatinine (UPC) ratios at baseline (lowest serum creatinine before biopsy), time of biopsy and 1 month after biopsy. We examined the effects of a change in UPC (DeltaUPC = UPC 1 month after biopsy-baseline UPC) on outcomes.
  
  
  RESULTS
  We identified 82 patients with both acute rejection and available data on proteinuria. Mean time (+/-SE) to acute rejection was 19 +/- 2.3 months, and patients were followed up for 38.7 +/- 2.6 months after transplant. Median DeltaUPC was 200 mg/g (95% confidence interval 0.00 to 0.300). Forty-two patients had a DeltaUPC > or =200 (high proteinuria group). Baseline characteristics were similar between high and low proteinuria groups except for more induction therapy with interleukin-2 receptor blockade in the former (71 vs. 47%, P = 0.04). Patient with DeltaUPC > or =200 had higher rates of graft loss (26 vs. 15%, P = 0.01) or combined graft loss or death (38 vs. 20%, P = 0.002 by log-rank). In univariate and multivariate Cox regression analyses, DeltaUPC > or =200 mg/g, sirolimus therapy 1 month after rejection and re-transplant status were significant factors associated with death-censored graft loss (hazard ratio (HR) 4.4, 14.9 and 6.2, P < or = 0.008) or combined graft loss or patient death (HR 3.8, 6.5 and 3.9, P < or = 0.03). Conclusions. An increase in proteinuria > or =200 mg/g after late acute rejection is associated with poor graft and patient outcomes. Clinical trials are needed to determine whether post-rejection anti-proteinuric strategies improve outcomes.
authors.affiliation: University of Wisconsin Madison SMPH, Department of Medicine, Wisconsin, USA. axd@medicine.wisc.edu
authors.forename: Arjang
authors.initials: A
authors.lastname: Djamali
authors.forename: Millie
authors.initials: M
authors.lastname: Samaniego
authors.forename: Jose
authors.initials: J
authors.lastname: Torrealba
authors.forename: John
authors.initials: J
authors.lastname: Pirsch
authors.forename: Brenda L
authors.initials: BL
authors.lastname: Muth
mesh_terms: D000328:Adult; D005260:Female; D006084:Graft Rejection / Q000209:etiology*; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007677:Kidney Function Tests; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011507:Proteinuria / Q000175:diagnosis / Q000209:etiology*; D012189:Retrospective Studies; D020123:Sirolimus / Q000627:therapeutic use; D015996:Survival Rate
chemical_list: D007166:Immunosuppressive Agents; D020123:Sirolimus