Risk factors for acute rejection in 806 cyclosporine-treated renal transplants: a multivariate analysis

Lymphocyte depletion and risk of acute rejection in renal transplant recipients at increased risk for delayed graft function

Delayed graft function (DGF) is a risk factor for acute rejection (AR) in renal transplant recipients, and KDIGO guidelines suggest use of lymphocyte-depletion induction when DGF is anticipated. We analyzed the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) database to assess the impact of induction immunosuppression on the risk of AR in deceased kidney recipients based on pretransplant risk of DGF using a validated model. Recipients were categorized into 4 groups based upon the induction immunosuppression: (1) Rabbit anti-thymocyte globulin (rATG); (2) Alemtuzumab (C1H); (3) IL2-receptor antagonists (IL2-RA; basiliximab or daclizumab), and (4) No antibody induction. The primary endpoint for analysis was a composite endpoint of treated AR or graft failure by 1-year posttransplantation. Compared to no antibody induction, rATG and C1H had consistently lower adjusted odds of the composite endpoint across all risk strata for DGF risk, whereas IL2-Ra was associated with increased adjusted odds of the composite endpoint with increasing DGF risk. When the induction agents were compared, rATG and C1H were associated with decreasing adjusted odds for the composite endpoint with increasing risk of DGF, especially at the higher risk spectrum of DGF. Consideration must be given to use of lymphocyte-depletion induction when the anticipated risk of DGF is increased.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Biomarkers in transplantation: Prospective, blinded measurement of predictive value for the flow cytometry crossmatch after negative antiglobulin crossmatch in kidney transplantation

This prospective, blinded observational study was conducted to measure the predictive value the of flow cytometric crossmatch for biopsy-proven acute rejection, graft loss, or death following kidney transplantation. Patients were selected for renal transplantation on the basis of a conventional antihuman globulin cytotoxic T-cell crossmatch. Flow crossmatch was performed simultaneously, but the results were not disclosed to the transplant team. A total of 257 kidney transplant recipients were enrolled in the study; 78 patients experienced biopsy-proven rejection in the first post-transplant year, and 41 patients lost their graft or died during the period of follow-up (mean: 2046 days). Kaplan-Meier estimates of rejection, graft loss, or patient death did not differ between subjects with a positive or negative flow crossmatch. Cox analyses showed no influence of the flow crossmatch on the risk of biopsy-proven acute rejection (P = 0.987). The sensitivity and specificity of the flow crossmatch for prediction of biopsy-proven rejection were 0.128 and 0.883, and the positive and negative post-test probabilities were 0.323 and 0.301, respectively. The magnitude of the channel shift did not influence the multivariate Cox regression model. The area under the receiver operating characteristic curve of the flow crossmatch was 0.483 (P = 0.71) and 0.572 (P = 0.38), respectively for the living and cadaver transplant recipients, indicating no discriminative value in this study population. Flow crossmatch appears to have no significant incremental value in predicting biopsy-proven acute rejection, graft loss, or death following kidney transplantation in patients who have a negative antihuman globulin cytotoxic T-cell crossmatch against their donor.