Improving Long-term Outcomes in Kidney Transplantation: Interventions After Transplant – Rejections and Delayed Graft Function

Reasons for loss of kidneys post-transplant include:

By Dr. Abhinav Humar

• Acute T cell-mediated rejection (TCMR)
• Antibody-mediated rejection (ABMR)
• Delayed graft function
• Viral infections/any type of opportunistic infections
• Recurrent and de novo diseases after transplant
• Drug-induced toxicity caused by the drugs used to prevent rejection is inherently nephrotoxic 

Majority of rejection happens in the first year of the transplant. In acute rejection or inflammation within 1 year of post-transplantation, the incidence of clinical acute TCMR is around 8-12%, clinical ABMR is around 5%, subclinical TCMR is around 8-15%, subclinical ABMR is 2 %, subclinical inflammation is around 40%. Acute rejection beyond 1-year post transplantation is seen in 15-20% of recipients of which TCMR is 10-15% and ABMR is 5-8%. Acute rejection negatively impacts long-term survival.

A prospective study conducted by Owoyemi, et al regarding the incidence and impact of acute rejection within one-year post kidney transplantation included adult kidney transplant recipients from 2013 to 2016 and those who had 1 or 2 biopsies within one 1-year post-transplant. They looked primarily into three outcomes: The function of the kidney (delta creatinine), the histology of the kidney (in terms of scarring), and graft survival. Results showed that only 17% of biopsies were having no inflammation and 44% showed subclinical inflammation. 

Early allograft inflammation and scarring associated with graft dysfunction and poor outcomes in renal transplant recipients with delayed graft function. The study concluded that Delayed graft function is associated with early tubule-interstitial inflammation that leads to chronic allograft damage and poor transplant outcomes.