title: High frequency of rejections in HIV-positive recipients of kidney transplantation: a single center prospective trial.
abstract: BACKGROUND
  This is a single institution report of the incidence of combined acute antibody-mediated rejection (ABMR) + acute cellular rejection (ACR) [mixed rejection] in HIV (+) kidney transplant recipients.
  
  
  METHODS
  We prospectively enrolled 92 HIV (+) patients who received a kidney transplant between 2001 and 2009. There were three cohorts: no rejection [n=26], ACR [n=53], and mixed rejections (ABMR and ACR) [n=13]. Immunosuppression comprised of basiliximab, cyclosporine, sirolimus, and steroid minimization. Fisher exact tests for categorical variables, t test for continuous variables, and Kaplan-Meier estimates were used to describe events.
  
  
  RESULTS
  Mixed rejections were seen in all 13 HIV (+) kidney transplant recipients (14%) with a median time to ABMR of 48 days. Acute cellular rejection occurred in 28% at 1 month and 55% at 12 months. eGFR was lower for recipients who experienced ABMR versus those experiencing ACR and those never experiencing rejection up to 3 years (14 ± 9.4 vs 19 ± 3.3 vs 29 ± 7.3 mL/min, respectively). Kaplan-Meier showed that graft survival up to 9 years was worse in recipients experiencing mixed rejection. Suboptimal donors with terminal creatinine greater than 2.5 mg/dL was associated with increased incidence of mixed rejections versus cellular rejections and no rejection (42% vs 17% vs. 8%, respectively).
  
  
  CONCLUSIONS
  Our single center study showed a relatively higher incidence of mixed rejection compared with that reported for non-HIV transplant recipients. A donor terminal serum creatinine greater than 2.5 mg/dL predicted mixed rejection, which was associated with poor outcomes. Donor selection and optimization of immunosuppression may be critical in these patients.
authors.affiliation: Division of Solid Organ Transplantation, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: Gregory E
authors.initials: GE
authors.lastname: Malat
authors.forename: Karthik M
authors.initials: KM
authors.lastname: Ranganna
authors.forename: Nicholas
authors.initials: N
authors.lastname: Sikalas
authors.forename: Longjin
authors.initials: L
authors.lastname: Liu
authors.forename: Rahul M
authors.initials: RM
authors.lastname: Jindal
authors.forename: Alden
authors.initials: A
authors.lastname: Doyle
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D015331:Cohort Studies; D003404:Creatinine / Q000097:blood; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology* / Q000276:immunology* / Q000517:prevention & control; D006085:Graft Survival; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D015994:Incidence; D016030:Kidney Transplantation / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012044:Regression Analysis; D012189:Retrospective Studies; D014019:Tissue Donors
chemical_list: D007166:Immunosuppressive Agents; D003404:Creatinine