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Factors Contributing to Acute Rejection Following Renal Transplantation

Paul E Morrissey, Steven Reinert, Reginald Gohh, Angelito Yango, Amitabh Gautam, Anthony P. Monaco
Rhode Island Hospital, Providence, RI

Objective:
We explored factors that contribute to the development of acute rejection (AR) after renal transplantation.
Design:
Analysis of a prospectively maintained database.
Setting:
Single institution, academic transplant practice.
Patients:
421 consecutive renal transplant recipients with a minimum of three months follow-up.
Interventions:
All biopsies were confirmed by ultrasound-guided biopsy. We analyzed both continuous (age, allograft survival, renal function) and nominal variables (sex, race, live vs. deceased donor, choice of immunosuppression, etc.) and compared each to the occurrence of AR.
Main Outcome Measure:
A two-tailed t-test or Pearson chi-squared analysis was utilized as appropriate. Multivariate analysis was applied to significant values (p < 0.05).
Results:
421 transplants (225 deceased donor and 201 living donor) were followed for a mean of 35±22 months. Over that period 72 allografts (17%) failed either due to patient death (N=43) or return to dialysis. 85 patients (20%) suffered AR. AR did not differ by recipient sex, race, transplant number, cold ischemic time, use of living donor, or delayed graft function. There was a trend toward fewer AR with induction therapy, which became strongly significant for the subgroup (N=180) receiving Thymoglobulin (p<0.0001). Fewer patients whose initial immunosuppression was tacrolimus experienced AR versus CsA (p<0.0001). Results of multivariate analysis are given below:
Variables associated with acute rejection
CategoryOdds RatioP value95% Conf. Interval
Antibody induction0.410.027.18-.90
Tacrolimus therapy0.450.065.19-1.05
Older recipient0.520.075.26-1.06
Noncompliance57.7<0.00016.2-537.0

Conclusions:
The risk of acute rejection is decreased by modifiable factors including the choice of immunosuppression. More importantly, the transplant recipient plays a disproportionate role in his or her own outcome with compliance identified as the greatest influence in preventing AR.

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