Year : 2008 | Volume
: 19 | Issue : 6 | Page : 948--951
Acute renal transplant rejections: A single center experience
Wael Latif Jabur1, Hareth M Mohammed Saaed2, Khalid Abdulla3,
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
Wael Latif Jabur
NMC Specialty Hospital, P.O. Box 7832, Dubai
United Arab Emirates
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.
|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;19:948-951
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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 ];19:948-951
Available from: https://www.sjkdt.org/text.asp?2008/19/6/948/43470
Acute renal graft rejections are encountered in all centers around the world in various degrees.  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
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:
HLA typing for A, B, and DR antigens for recipients and donors.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.
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.
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  with some exceptions. ,, The lack of sensitive methods to detect preformed anti-bodies in the recipient serum and the lack of HLA- matching considered by some  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  (instead of the lymphocytotxicity method which we are using) may have helped in this respect. Incidences of acute humoral rejection of 25%  and 30%  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. 
In our study, the incidence of rejection in both related and unrelated donor transplantations was the same. A similar finding was reported by others.  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.  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  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%  and 28%  were reported by others including the Mansoura group  from Egypt. Smak Gregoor et al  concluded that steroids can be withdrawn safely at the end of six months post transplantation in patients on triple therapy. A European study  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  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  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.
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