Home About us Current issue Ahead of Print Back issues Submission Instructions Advertise Contact Login   

Search Article 
Advanced search 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 828 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 

ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 6  |  Page : 948-951
Acute renal transplant rejections: A single center experience

1 NMC Specialty Hospital, Dubai, United Arab Emirates
2 Al-Kasimi General Hospital, Sharjah, United Arab Emirates
3 College of Medicine, AL-Nahraen University, Baghdad, Iraq

Click here for correspondence address and email


We undertook this observational study to assess the incidence of acute rejections (AR) in the first six months after transplantation at Al-Karama Hospital, Iraq. Sixty eight patients (49 males and 19 females) underwent renal transplantation in 2006 and were followed up weekly. Forty six received kidneys from related donors and 22 from unrelated donors. During the first six months after transplantation AR occurred in 16 patients (23%); 11 (23%) related and 5 (23%) unrelated donor transplantation. We conclude that the incidence of acute rejection was similar in related and unrelated donor transplantation and the general incidence was comparable to that reported from most centers.

Keywords: Renal transplantation, Acute rejection

How to cite this article:
Jabur WL, Mohammed Saaed HM, Abdulla K. Acute renal transplant rejections: A single center experience. Saudi J Kidney Dis Transpl 2008;19:948-51

How to cite this URL:
Jabur WL, Mohammed Saaed HM, Abdulla K. Acute renal transplant rejections: A single center experience. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2022 Dec 8];19:948-51. Available from: https://www.sjkdt.org/text.asp?2008/19/6/948/43470

   Introduction Top

Acute renal graft rejections are encountered in all centers around the world in various degrees. [1] In Iraq there are several centers for kidney transplantation and true incidence of acute rejection is not known. We therefore conducted this study to evaluate the incidence of acute rejection occurring within the first six months after renal transplantation in patients followed up in one of the main center for renal transplantation in Iraq.

   Patients and Methods Top

Sixty eight patients, 49 (60%) males and 19 (40%) females who had renal transplantation in the second half of 2005 and first half of 2006 and were attending Al-Karama transplant clinic for follow up were studied retrospec­tively. Sixty one patients (90%) had their transplantation operation done in Al-Karama hospital.

Age of patients ranged from 13 to 50 years. The cause of renal failure was unknown in majority of the patients besides renal stone disease, diabetes mellitus, systemic lupus ery­thematosus, polycystic kidney disease and chronic glomerulonephritis were the main causes. All patients were undergoing regular hemodialysis for periods ranging from 2 months to 2 years prior to transplantation.

Forty six patients (67%) received kidneys from related donors with 50% or more HLA histocompatibility and, twenty two (32%) from unrelated donors with HLA histocompatibility of 25% or less. The following immunological tests were done before transplantation:

  1. HLA typing for A, B, and DR antigens for recipients and donors.
  2. Direct cross-match for detection of pre­formed antibodies against donor's antigens in recipient's plasma.

HLA matching between donors and recipients was as follows: 100% matching in 7 patients, 75% in 9, 50% in 30, 25% in 11 and 0% in 11.

One patient had a previous transplant and another two previous transplants.

All donors were ABO compatible, and cross­match negative.

Unrelated donors were accepted when sui­table related donors could not be found.

Basiliximab injections were used for induc­tion and triple drugs for maintenance.

Prednisolone was used with either Tacro­limus and (Mycophenolate Mofetil) MMF in high risk patients or Cyclosporin (Neoral) and Azathioprine in other patients as a triple drug regimen.

The reciepient was considered high risk if it was a child, second kidney transplantation, after an episode of acute rejection or zero HLA histocompatibility.

Patients were usually discharged from hos­pital two weeks after operation and followed up weekly in the outpatient clinic. In each visit the patient was examined clinically. Weekly laboratory investigations included serum crea­tinine, blood urea nitrogen, serum electrolytes, urinalysis and Cyclosporin/Tacrolimus serum levels when available. A rise in serum crea­tinine of 0.2 mg/dL was considered abnormal after confirmation of the lab result.

Acute rejection was confirmed by renal biop­sy in 8 patients. In the rest the diagnosis depended on the clinical picture supported by a prompt response to anti-rejection therapy. C4d immunostaining was not available.

   Results Top

Sixteen patients (23.5%) were diagnosed as having acute rejection [Table 1]; 11 of them received their kidneys from related donors (representing 23% of that group) and 5 from unrelated donors (also representing 23% of the group).

Three out of seven patients of age below 18 years of age had acute rejection. Acute rejec­tion was confirmed by renal biopsy in 8 patients. All of them showed cellular rejection, which was grade one Banff classification in six and grade two in two. In case of suspicion of humoral rejection, cross matching with donor lymphocytes was repeated and was found negative in all of them.

Twelve (75%) of the events of acute rejection were encountered in the first month post transplantation.

11 of the 16 (68 %) acute rejection episodes were totally reversed by high dose methyl­prednisolone (1000 mg for three successive days.) Two patients (12.5%) recovered with mild allograft failure after pulse steroids and switching immunosuppression to Tacrolimus and MMF. One patient (6.2%) underwent allo­graft nephrectomy and returned to hemodia­lysis.

Two patients (12.5%) died during the acute phase of rejection.

   Discussion Top

The incidence of acute rejection of 23% and graft loss of 1.4% found in our study is com­parable to many reports in the literature. A rejection rate of around 20% and a graft loss of less than 1% is observed in most centers in the world [2] with some exceptions. [3],[4],[5] The lack of sensitive methods to detect preformed anti-bodies in the recipient serum and the lack of HLA- matching considered by some [6] as an important predictor of rejection might have been factors involved in our patients. This at the same time provides opportunities for im­provement.

Rejection in our biopsied patients was cellu­lar in type responding to pulse therapy how­ever, we cannot completely exclude a humoral element in the other three patients who either did not respond or responded partially. C4d immunostaining of biopsies and the use of ELISA to detect serum antibodies [8] (instead of the lymphocytotxicity method which we are using) may have helped in this respect. Incidences of acute humoral rejection of 25% [8] and 30% [7] were reported in some other studies and repeated cross match using flow cytometry was positive for donor specific antibodies.

In two of our patients acute rejection was temporally related to an interruption of Cy­closporin intake. Responding to methylpred­nisolone consistent with the results of Smakgregoor et al. [9]

In our study, the incidence of rejection in both related and unrelated donor transplan­tations was the same. A similar finding was reported by others. [10] The results of more than 2,000 unrelated donor transplants performed in the United States since 1991 were similar to the results of grafts from parents or other relatives sharing one HLA haplotype. [11] A better outcome is only provided by an HLA identical kidney.

A high incidence of acute rejection (42%) among younger patients less than 18 years old was associated with death in two of the pa­tients. This is consistent with the previous reports of higher incidences of acute rejection in pediatric renal transplant recipients. In the report of NAPRTIC [9] the incidence in pediatric patients was 40% before and 12% after the year 2000, a difference attributed to better and more specific immunosuppressants. Incidences of 38% [12] and 28% [13] were reported by others including the Mansoura group [14] from Egypt. Smak Gregoor et al [9] concluded that steroids can be withdrawn safely at the end of six months post transplantation in patients on triple therapy. A European study [15] to the con­trary showed that steroid withdrawal in pa­tients on triple therapy carries a considerable risk of acute rejection. Similarly a study in adults from USA [16] also concluded that steroid withdrawal significantly increased the risk of acute rejection especially in black patients. Two of our patient's acute rejection developed when steroid withdrawal was attempted after six months of transplantation. Agarwal and Pescovitz [17] in their review have discussed other successful steroid-sparing regimen that are as effective and avoid the chronic morbi­dity of steroids in the pediatric population.

Azathioprine was withdrawn in three of our patients, due to bone marrow suppression and raised liver enzymes, and maintained success­fully on cyclosporine and prednisolone.

In conclusion the incidence of acute rejection in the initial six months at our center was overall, and in related and unrelated renal transplantation individually, was comparable to the reported incidence in the literature.

   References Top

1.Wolf R. The state of kidney transplantation in the United States. Semin Dial 2005;18(6):453-­5.  Back to cited text no. 1    
2.Humar A, Matas AJ, Surgical complications after kidney transplantation. Semin Dial 2005; 18(6):505-10.  Back to cited text no. 2    
3.Al-Wakeel J, Mitwalli AH, Tarif N, et al. Living unrelated renal transplant: Outcome and issues. Saudi J kidney Dis Transpl 2000;11 (4):553-8.  Back to cited text no. 3    
4.Dharnidharka VR, Stablein DM, Harmon WE. Post-transplant infections now exceed acute rejection as cause of hospitalization: a report of the NAPRTCS. Am J Transplant 2004;4(3): 384-9.  Back to cited text no. 4    
5.First MR, Improving long-term renal transplant outcomes with Tacrolimus: Speculation vs evidence. Nephrol Dial Transplant 2004;19 (Supp 6):17-22.  Back to cited text no. 5    
6.Frohn C, Fricke L, Puchta JC, Kirchner H. The effect of HLA-C matching on acute renal transplant rejection. Nephrol Dial Ttansplant 2001;16(2):355-60.  Back to cited text no. 6    
7.Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation: II, morphology, immunopathology and pathologic classification. J Am Soc Nephrol 2002;13(3):779-87.  Back to cited text no. 7    
8.Fernandez-Fresnedo G, Pastor JM, Lopez­Hoyos M, et al. Relationship of donor-specific class-I anti-HLA antibodies detected by ELISA after kidney transplantation on the deve­lopment of acute rejection and graft survival. Nephrol Dial Ttansplant 2003;18(5):990-5.  Back to cited text no. 8    
9.Smak Gregoor P, de Sevaux RG, Ligtenberg G, et al. Withdrawal of cyclosporin or pred­nisone six months after kidney transplantation in patients on triple drug therapy: a rand­omized prospective multicenter study. J Am Soc Nephrol 2002;13(5):1365-73.  Back to cited text no. 9    
10.Davis CL, Delmonico FL. Living-donor kidney transplantation: a review of the current practice for the live donor. J Am Soc Nephrol 2005;16(7):2098-110.  Back to cited text no. 10    
11.Cecka JM. Kidney donation from unrelated living donors. Saudi J Kidney Dis Transpl 1999;10(4):464-9.  Back to cited text no. 11    
12.Rosati P, Pinto V, Delucchi A, et al. Pediatric renal transplantation: 13 years of experience - report from the Chilean cooperative multicenter group. Transplant Proc 2005;37 (3):1569-73.  Back to cited text no. 12    
13.Emiroglu R, Moray G, Sevmis S, Sozen M, Biligin N, Haberal M. Long-term results of paediatric renal transplantation at one center in Turkey. Transplant Proc 2005;37(2):675-8.  Back to cited text no. 13    
14.Elhusseini A, Foda M, Bakr M, Shokeir A, Sobh M, Ghoneim M. Pediatric live-donor kidney transplantation in Mansoura Urology and Nephrology Center: A 28-Year perspective. Pediatr Nephrol 2006;21(10): 1464-70.  Back to cited text no. 14    
15.Vanrenterghem Y, Lebranchu Y, Hene RJ, Opperheim F, Berg EK. Double-blind com­parison of two corticosteroid regimens plus Mycophenolate Mofetil and Cyclosporin for prevention of acute renal allograft rejection. Transplantation 2000;70(9):1352-9.  Back to cited text no. 15    
16.Ahsan N, Hircik D, Matas A, et al. Prednisone withdrawal in kidney transplant recipients on Cyclosporine and MMF: a prospective randomized study. Transplantation 1999;68 (12):1865-74.  Back to cited text no. 16    
17.Agarwal A, Pescovitz MD. Immunosuppression in pediatric solid organ transplantation. Semin Pediatr Surg 2006;15(3):142-52.  Back to cited text no. 17    

Correspondence Address:
Wael Latif Jabur
NMC Specialty Hospital, P.O. Box 7832, Dubai
United Arab Emirates
Login to access the Email id

Source of Support: None, Conflict of Interest: None

PMID: 18974582

Rights and PermissionsRights and Permissions


  [Table 1]


    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Patients and Methods
    Article Tables

 Article Access Statistics
    PDF Downloaded397    
    Comments [Add]    

Recommend this journal