Renal transplantation
Acute rejection
Factors Contributing to Acute Rejection in Renal Transplantation: The Role of Noncompliance

https://doi.org/10.1016/j.transproceed.2005.03.017Get rights and content

Abstract

Early episodes of acute rejection after renal transplantation reflect inadequate immunosuppression at a time of heightened immune challenge. Late acute rejection episodes, however, are less likely related to inadequacy of immunosuppression and may be due to patient noncompliance or overzealous weaning of immunosuppression. We evaluated 443 consecutive renal transplant recipients to determine the incidence and etiology of acute rejection. All episodes were confirmed by ultrasound-guided biopsy. The cause of each acute rejection was determined by chart review. Medication compliance was determined by history at the time of admission for biopsy.

Over a follow-up period of 42 ± 22 months, 87 patients (20%) suffered acute rejection. There was a trend toward fewer episodes of acute rejection with thymoglobulin induction and tacrolimus-based immunosuppression. Younger recipients had an increased risk of acute rejection (odds ratio 0.47, range 0.24–0.91, P = .027). Patient noncompliance with immunosuppression was associated with late acute rejection (P = .0002). Acute rejection increased the risk of allograft failure (P < .0001).

Modifiable factors, including the choice of immunosuppression, reduce the risk of acute rejection. More importantly, the transplant recipient plays a substantial role in the maintenance of their allograft health through compliance with immunosuppressive drug therapy. Future strategies to improve compliance, including increased vigilance in high-risk patient groups, frequent medication review, and laboratory testing, should be encouraged.

Section snippets

Methods

We studied all kidney transplant recipients at Rhode Island Hospital who received a kidney between March 1997 and June 2004. The patients were tracked through a prospective institutional database, which contained all episodes of rejection. Acute rejection was uniformly confirmed by kidney allograft biopsy, interpreted by a renal pathologist. The time from transplantation to the first episode of acute rejection was calculated. Repeat episodes of acute rejection, occurring in 15 of 87 patients,

Results

The study included 443 patients whose allografts survived greater than 30 days after transplantation. The mean patient follow-up was 44 ± 24 months (range 12–94 months), while the mean allograft survival was 41 ± 23 months. Eighty-seven patients (20%) suffered 107 episodes of acute rejection, including 47 (11%) in the first 6 months after transplantation. Fifteen patients had two or more episodes, with 10 of these confined to the first 6 months after transplantation. The incidence of acute

Discussion

Several factors increase the risk of acute rejection, including young recipient age, low levels of immunosuppression, DGF, prior sensitization to antihuman leukocyte antibodies, and patient nonadherence to immunosuppression.3 Following successful engraftment, renal transplantation requires lifelong immunosuppression, necessitating indefinite, twice daily drug therapy. The drug regimens are costly and associated with a broad spectrum of unpleasant side effects. As a result, approximately 20% to

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    Regular and adequate dosing is required to achieve therapeutic outcomes by IS therapy. Already minor deviations from the dosing schedule suffice to increase the risk of future graft loss and death [1,2,3,4]. Non-adherence can occur early after transplantation and has been shown to increase over time [5,6].

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