Radiation therapy for renal transplant rejection refractory to pulse steroids and OKT3

Local allograft irradiation as an adjunct for treating severe resistant rejection after liver transplantation in adults

Acute rejection after liver transplantation occurs in one-third of all recipients and can be managed with conventional rejection therapy in the majority of cases. In rare instances, patients with severe acute rejection may be refractory to or have contraindications for conventional therapies. This case series evaluates the role of local allograft irradiation (LAI) as an adjunct for patients with rejection that is refractory to or contraindicated for conventional therapies. Additionally, the literature on the use of radiation therapy for reversing rejection in solid organ transplantation is reviewed. Five patients underwent 9 LAI treatments: 2 had refractory rejection, and 1 each had a malignancy, a concurrent life-threatening infection, and serum sickness with antibody therapy. Conventional rejection therapies included steroids, calcineurin inhibitors, and antithymocyte globulin. LAI consisted of 3 cycles of 1.5 Gy directed toward the liver allograft. Two of the 5 patients remained alive with excellent graft function. Six of the 9 treatments were successful in rescuing the liver allograft (reversing the rejection episode). Treatment success was associated with lower pretreatment serum bilirubin levels and higher pretreatment alanine aminotransferase levels. Compared with patients with immunosuppression-responsive severe acute rejection, those requiring LAI trended toward a later onset of first rejection. In conclusion, local irradiation of liver allografts can be a useful adjunct in patients for whom conventional options have been exhausted or cannot be used. The ability of LAI to reverse allograft dysfunction and promote patient survival appears to be greatest before the onset of severe cholestatic injury.

Local graft irradiation for kidney allograft rejection: a case series and review of the literature

Introduction:

Due to its immunosuppressive properties, local graft irradiation (LGI) has been proposed as a second line therapy for treatment of acute kidney rejection.

Case Presentation:

In this case-series we report 6 patients with biopsy proven acute kidney allograft rejection refractory to conventional antirejection therapy who underwent LGI for treatment of acute rejection at our center. Three of these patients had living donor transplants, 2 had deceased donor transplants, and one had received a simultaneous kidney/pancreas transplant. All patients were treated with anti thymocyte-globulin or muromonab-CD3, and intravenous steroids for initial treatment of rejection. Three patients also received intravenous immunoglobulin. LGI was tried as a last resort and was well tolerated and resulted in either improvement or stabilization of renal function in 5 patients. One patient could not be given the complete course of chemical immunosuppression for treatment of rejection due to concomitant cryptococcal meningitis and was switched to LGI with good short-term response.

Discussion:

Our results suggest that LGI could be considered a second line therapy to the conventional anti-rejection therapy for patients with refractory acute kidney allograft rejection, or for patients who cannot receive systemic immunosuppression due to severe infection.

Radiotherapy for Rejection of Renal Transplant Allografts Refractory to Medical Immunosuppression

OBJECTIVE

To evaluate the outcome and prognostic factors of patients who underwent local graft irradiation for acute renal allograft rejection refractory to modern immunosuppressive medications.

METHODS

From 1996 to 2005, 33 patients received local graft irradiation (LGI), with 3 patients receiving 2 courses of radiation. Graft rejection was diagnosed when a rise in creatinine prompted a renal biopsy that demonstrated acute allograft rejection. Upon failure of medical immunosuppresion to resolve rejection, patients were then referred by the organ transplant team for LGI. The median dose was 800 cGy (range, 600-800 cGy), and was given in 200 cGy fractions generally using AP/PA fields. A retrospective review was conducted to determine dialysis-free survival, defined as the date from initiation of radiation therapy to date of hemodialysis placement, and to analyze potential factors that may predict dialysis free survival.

RESULTS

Median follow-up from date of radiation therapy to date of last follow-up was 25 months (range, 0.9-99.4 months). The median time between allograft transplantation and radiation therapy was 17.8 months. For the entire group of patients, 20.6% were alive with a functioning graft. The median dialysis-free survival for the entire group was 3.8 months. The median dialysis-free survival for those patients not on dialysis at time of irradiation versus those patients on dialysis was significantly different (5.6 versus 0 months, P = 0.02).

CONCLUSION

In renal allograft transplant recipients who experienced acute rejection episodes refractory to modern chemical immunosuppression, LGI was well tolerated and remains a viable salvage treatment option.

Liver allograft radiotherapy to treat rejection in children: efficacy in orthotopic liver transplantation and long-term safety

BACKGROUND

We studied, retrospectively, the efficacy to control rejection and long-term safety of liver allograft radiotherapy (RT) performed in 14 children. Long-term safety data were collected with the prospect of possible use of RT in liver cell transplantation (LCT).

METHODS

Immune suppression included cyclosporine, azathioprine and prednisone. In case of intractable rejection, low-dose allograft RT was administered daily for 3 days, and short-term efficacy was evaluated by liver enzyme assays and histology. The long-term outcome was compared with that of 122 patients undergone transplantation and who had similar treatment, but no RT.

RESULTS

Survival at 15 years was 71.4% vs 69.7% in the comparison group. In the RT group, rejection control was complete in six of 14 children and partial in two, all being alive and well 14-18 years later. Ten of 14 children had follow-up biopsy. Six children had normal histology and four had mild unspecific fibrosis. The long-term follow-up biopsy in the comparison group showed fibrosis in 42 of 85 children. The incidence of complications was similar in both groups.

CONCLUSIONS

This series shows that, such a RT regimen appeared to be efficient and safe as a rescue treatment for acute rejection. Provided that further investigations in animal models show a certain benefit of low-dose irradiation around LCT, such a regimen could be proposed in human liver cell transplant programmes.

Outcome of radiation therapy for renal transplant rejection refractory to chemical immunosuppression

Twenty consecutive patients with kidney graft rejection refractory to chemical immunosuppression were treated with local irradiation to the transplanted renal graft (3 x 1.5 Gy). Ten patients were complete responders (median follow-up: 47 months). Six patients were partial responders and failed after 1-4 months. Four patients did not respond.

New scoring system identifies kidney outcome with radiation therapy in acute renal allograft rejection

PURPOSE

To evaluate the role of radiation therapy for acute refractory renal rejection after failure of medical intervention, and to identify risk factors that influence graft survival following radiation therapy.

METHODS

Between June 1989 and December 1995, 53 renal transplant recipients (34 men and 19 women) were treated with localized radiation therapy for acute renal allograft rejection. Graft rejection was defined as an increase in serum creatinine with histologic evidence of rejection on renal biopsy. Ninety-one percent were cadaveric transplant recipients. The majority of patients who experienced acute graft rejection initially received corticosteroid therapy, except for 25% who were referred for radiation therapy and steroids for the first rejection. In more recent years, patients with moderate or severe steroid-resistant or recurrent rejection received OKT3, a polyclonal antilymphocyte antibody (ATGAM), tacrolimus (FK506), or mycophenolate mofetil (MMF). Patients who failed to respond to medical treatment were then referred for radiation therapy. Ultrasound was performed for kidney localization. Treatment consisted of a dose of 600 cGy given in 3 or 4 fractions using 6 MV photons, delivered AP or AP/PA.

RESULTS

The overall actuarial graft survival from the initiation of RT was 83% at 1 month, 60% at 1 year, and 36% at 5 years. The median follow-up from the date of transplant to the last follow-up was 22 months. The median time from the date of transplant to the initiation of radiotherapy was 3 months, and the median time from the initiation of radiotherapy to the last follow-up was 10 months. Variables evaluated were as follows: human leukocyte antigen matching on HLA-A, HLA-B, and HLA-DR, the transplant panel-reactive antibodies (PRA) at transplantation, number of acute rejection episodes, interval from the date of the transplant to the first rejection, serum creatinine levels at the time of the first radiation treatment, number of transplants, and concomitant immunosuppressive therapy. Independent factors examined by Cox regression modeling were: gender (p = 0.005), creatinine levels (p = 0.000), HLA-DR (p70% (p = 0.014). Each factor was scored using integral coefficients to generate four different groups. The Kaplan-Meier survival analyzed by group produces an interpretable separation of the risk factors for graft loss.

CONCLUSIONS

The outcome in patients treated with radiation therapy for acute renal graft rejection can be predicted by a novel scoring system. Patients with scores of three or less are able to achieve 100% renal graft salvage, while patients who have scores of 12 or higher are not able to be salvaged with the current radiation therapy regimen. Future studies should be directed toward identifying more effective treatment for patients who have a high score based on our criteria. The scoring system should be utilized to identify patients at risk who could benefit from radiation therapy. Further study with a randomized trial utilizing this scoring system is needed to confirm the validity of the scoring system in predicting graft survival and the efficacy of radiation in patients who receive radiation therapy for acute graft rejection.

[Role of radiotherapy in benign diseases]

Radiation therapy of benign diseases represent a wide panel of indications. Some indications are clearly identified as treatment of arteriovenous malformations (AVM), hyperthyroid ophtalmopathy, postoperative heterotopic bone formations or keloid scars. Some indications are under evaluation as complications induced by neo-vessels of age-related macular degeneration or coronary restenosis after angioplasty. Some indications remain controversial with poor evidence of efficiency as treatment of bursitis, tendinitis or Dupuytren's disease. Some indications are now obsolete such as warts, or contra-indicated as treatment of infant and children.

Local graft irradiation after failure of modern immunosuppression in acute cellular and vascular graft rejection

PURPOSE

With improved chemical immunosuppressive agents, approximately 90% of rejection episodes can be reversed. However, in situations of failed immunosuppression, graft loss becomes inevitable. Our objective is to assess the efficacy of local graft irradiation (LGI) as an effort of last resort in a contemporary group of patients in whom graft failure to irreversible cellular and vascular rejection is imminent.

METHODS AND MATERIALS

A total of 308 renal transplantations were performed at our institution from 1992 to 1995, and an overall 1-year graft survival rate of 90% has been seen as a result of improvement in chemical immunosuppression. However, 6 patients were referred for LGI when all other measures failed to reverse the rejection crisis. Parameters that were studied in these patients included graft function and postirradiation graft histology.

RESULTS

Irradiation was associated with reversal of the rejection crisis and resulted in documented histological long-term graft survival in 1 of the 6 patients (17%). Two of the six patients (33%) had reversal of the rejection episode based on postirradiation biopsy of the renal allograft. Three of the six patients showed some level of clinical improvement of graft function for varying periods of time. One patient maintained stable allograft function without deterioration and with continued independence from hemodialysis. One recipient died from sepsis despite histologic improvement after irradiation.

CONCLUSIONS

Our impression is that LGI is indicated when all other measures have failed to reverse an acute rejection episode in the transplanted renal allograft. The role of radiation in this setting should be studied further.