Acute Rejection and Graft Loss
The mean serum creatinine levels at 1, 5, and 12 years in steroid-free patients were 1.2, 1.3, and 1.5 mg/dL, respectively. Patients (9.2%) experienced early acute rejection and 3.5% of patients experienced subclinical rejection, and overall the biopsy-proven acute rejection-free survival at 12 years was 83%. All rejections were biopsy-proven. IF/TA was seen in 8.5% biopsies out of 4258 biopsies by 10 years.
About 88% and 85% of biopsies were normal at 5 and 10 years, respectively. The cumulative incidence of graft loss was 6.56% at 12.3 years. The causes of graft loss are listed in Table 2. Retransplantation was done in 4.0% of patients; 45 patients received a second transplant and 2 patients received a third transplant. Hemodialysis was required in 23 (2.0%) patients, due to acute kidney injury; one patient developed primary nonfunction of the graft.
Complications After Transplantation
NODAT was observed in 1.5% at 1 year and 6.1% at 12 years. Cataract surgery was not needed in patients aged below 40 years in our study.
Leucopenia was seen in 34.4% of patients. Patients (72 [6.3%]) had pretransplant hepatitis, and 36 (3%) patients had new-onset or relapsed hepatitis following transplantation. The graft and overall survival rates were significantly lower in patients with hepatitis after transplantation compared with patients without hepatitis.
Routine screening was not conducted for detection of BK virus in most patients. Screening was done only in case of any suspicious histological findings from protocol or indicated biopsies, in which case a BK virus polymerase chain reaction test was done to detect BK viremia. BK virus infection was seen in 17 (1.4%) patients, of whom 2 patients lost the graft. Immunosuppression was reduced in patients detected with BK viremia. Testing for parvovirus was done only for those patients who had anemia due to pure red cell aplasia. Two patients were positive for parvovirus infection, and they responded well to intravenous immunoglobulin. Tuberculosis was detected in 44 (3.8%) patients after transplantation. There were 4 patients (0.3%) with invasive fungal infections, of whom 2 had mucormycosis: one survived following treatment, while the other died. Cryptococcal meningitis and pulmonary aspergillosis resulted in the death of 2 patients.
There were no new fractures in the patients who remained steroid-free for the duration of follow-up, while there were 3 hip fractures among patients who required steroids. The BMD values of the spine and hip at baseline were compared to the values at 5 years after transplantation in 571 patients. There was no significant improvement in BMD in our subjects.
Posttransplant malignancy was seen in 15 patients. Posttransplant lymphoproliferative disease (PTLD) was observed in 7 (0.60%) (3 treated and in complete remission, remaining 4 died) out of 15 patients. Native renal cell carcinoma was seen in 5 patients, all of whom underwent nephrectomies.
About 61% of patients did not require antihypertensive medications at the end of the first year, and 34.8% did not require antihypertensive medications at the end of the fifth year after transplantation.
Incidence of Death
Sixty patients (5.2%) died during the study period. Infection was the leading cause of death, followed by stroke, chronic hepatitis, and noncompliance with therapy (Figure 5).
In the current retrospective analysis, we found that a systematic approach to immunosuppression with low-dose preoperative rituximab and thymoglobulin induction and steroid-free maintenance after the first week of kidney transplantation along with incorporating protocol biopsies resulted in favorable patient and graft survival with acceptable rates of acute rejection and reduced incidence of steroid-related complications.
There was no control group in this analysis. This study was started as a pilot project and we found there was no NODAT in first 25 patients at 4 weeks. NODAT in historical cohort (no thymoglobulin induction) who received prednisolone in addition to MMF and tacrolimus was 43% at 1 month and 24.5% at 1 year, so we thought it would be improper to keep control group. Other long-term studies involving steroid-free maintenance immunosuppression, and rapid discontinuation of prednisone (RDP) protocols have also not reported the use of a control group.20,21
In our study, a comparative analysis of the results between living donor (LD) and deceased donor (DD) transplant recipients was not conducted, as the proportion of patients in both the categories was not balanced, with about 95.4% LD transplant recipients.
The patient survival rates in our study were 97.7%, 94.8%, and 92.4% at 1, 5, and 12 years, respectively. In an earlier study by Rizzari et al22 in transplant recipients (64% LD and 36% DD), treated with RDP protocol, the patient survival rates at 1, 5, and 10 years were 98%, 90%, and 71% for LD transplant recipients and 95%, 86%, and 62% for DD recipients, respectively. Another prospective randomized study by Suszynski et al21 evaluated an RDP protocol and compared 3 different maintenance immunosuppression regimens. The 10-year patient survival rate was comparable across the 3 regimens and was ≈70%.
The graft survival rate at 1, 5, and 12 years in our study was 97.2%, 90.9%, and 86.1%, respectively; and death-censored graft survival was 93.5% at 12 years. The graft survival rates reported by Rizzari et al22 were 96%, 82%, and 61% for LD recipients and 94%, 77%, and 51% for DD recipients at 1, 5, and 10 years, respectively. In the study by Suszynski et al,21 the overall 10-year graft survival and death-censored graft survival rates were ≈60% and 80%, respectively. In another retrospective study by El-Faramawi et al20 evaluating the outcomes of complete steroid-avoidance immunosuppression, the graft survival rates at 1, 5, and 7 years posttransplantation were 95%, 77%, and 72%, respectively.
In the organ procurement and transplantation network (OPTN) report published in 2016, the 5- and 10-year all-cause graft failure was 26.5% and >50% in DD transplant recipients and 14.3% and >35% in LD transplant recipients, respectively.24 These graft failure rates are higher than the graft loss of 6.56% noted in our study at 12.3 years. All-cause graft failure in our study was 11.6% at 12 years.
The reasons for the improved patient and graft survival rates in our study could have been the addition of low-dose preoperative rituximab to thymoglobulin induction (a novel induction method rarely cited in the literature), aggressive cardiovascular screening (resulting in low posttransplant mortality due to ischemic heart disease), lowered infection rate due to steroid withdrawal, and aggressive biopsy procedure—which included protocol biopsies. The utility of protocol biopsies in detecting multiple problems, including subclinical acute rejection, BK viremia, CNI toxicity, and IF/TA among others, remains proven in earlier studies.25-29 Protocol biopsies have also been found to guide early treatment, lower the graft loss, and improve functional outcomes after kidney transplantation.25,26
The early acute rejection rate in our study was 12.7%, which included 3.5% subclinical rejection. In the study by El-Faramawi et al,20 the acute rejection rate with a complete steroid-avoidance protocol within the first year of transplantation was 19%. The 10-year biopsy-proven acute rejection rate with an RDP protocol in the study by Suszynski et al21 was in the range of 20%–30%.
The lower rates of acute rejection in our study may be due to thymoglobulin induction, regular use of preoperative low-dose rituximab, and consistent use of tacrolimus-based immunosuppression in all study patients; everolimus was administered only in cases of suspected CNI toxicity. Induction with thymoglobulin and tacrolimus-based immunosuppression has been proposed to lower acute rejection in earlier studies.30 In a recent study that randomized de novo kidney transplant recipients to convert to everolimus or remain on standard CNI therapy at 10–14 weeks after transplantation, the rates of biopsy-proven acute rejection were lower in the group that continued to receive tacrolimus compared to the group that received everolimus. Furthermore, discontinuation due to adverse events was more in the everolimus group compared to the CNI group.31 A recent meta-analysis by Zhao et al32 demonstrated significantly lower rates of acute rejection in sensitized patients treated with rituximab before renal transplantation. Furthermore, induction with low-dose rituximab has been found to result in low acute antibody-mediated rejection rates and high patient and graft survival rates in ABO-incompatible kidney transplantations as well.33
The use of protocol biopsies may be a plausible explanation for the lower rates of graft loss in our study. Literature stands proof of the potential role of protocol biopsies in detecting subclinical acute rejection,34 chronic allograft nephropathy,35 and inflammation after renal transplantation.36 Early detection and management of these conditions may help lower the graft loss and prevent the decline in graft function and survival.25,37,38 Aggressive use of biopsies avoided the unnecessary use of steroid pulse therapy for the treatment of acute rejection empirically.
The low dose of rituximab used in our study is aligned with the doses used in other studies for the prevention of antibody-mediated acute rejection in ABO-incompatible kidney transplantations.33,39-41 The dose of thymoglobulin used for induction is also in line with the dose used in other long-term kidney transplantation studies with RDP protocol.21 Detection of peripheral CD20/CD19 levels to assess the effect of rituximab was not done in our study, as several studies have proven the efficacy of rituximab in lowering the CD20/CD19 levels, when used at doses similar to that used in this study.39-41
The NODAT rates in our study were very low, which are 1.5% at 1 year and 6.1% at 12 years. Similar results were reported by Rizzari et al,22 with 10-year NODAT rates of 7% and 11% in LD and DD recipients, respectively. Furthermore, the NODAT results in our cohort are comparable to the figures mentioned in the OPTN report.24
Cataract surgery was not required in patients aged below 40 years. Rizzari et al22 also reported a significantly lower incidence of cataract complications with the RDP protocol compared to historical controls.
In our study, graft and overall survival rates were significantly lower in patients with hepatitis virus infection. Recent studies reveal a significant association between hepatitis B virus infection and poor patient and graft survival in kidney transplant recipients.42,43 A significant association between hepatitis C virus infection and decreased graft survival and increased rate of acute rejection has also been reported.43
The incidence of BK viremia noted in our study (1.4%) is less than that reported with prednisone-based immunosuppression (13%) in previous studies.44 Furthermore, steroid maintenance therapy has also been reported to increase the risk of BK virus replication by about 38%.45
Prednisolone avoidance decreased the risk of fractures in our study; 4 fractures were noted in patients who received low-dose prednisolone versus no fractures in patients in the prednisolone-free group. Rizzari et al22 also reported a lower incidence of fractures in RDP-treated DD nondiabetic recipients.
The incidence of PTLD (0.60%) in our study is relatively lower than the 10-year PTLD noted in the study by Rizzari et al22 (0.3% and 2% in LD recipients with and without diabetes, and 6% and 1% in DD recipients with and without diabetes, respectively). Our rates are also aligned with the incidence of PTLD at 5 years in the OPTN report (1.7% and 0.5% for patients who were Epstein-Barr virus-negative and virus-positive at the time of transplant, respectively).24
Fewer patients needed antihypertensive treatment and coupled with less NODAT after transplantation in our study also probably improved survival. A meta-analysis by Knight and Morris46 reported a significantly reduced incidence of hypertension after renal transplantation with steroid avoidance or withdrawal strategies.
The overall incidence of death was low in our study (5.21%). This could be attributed to the aggressive cardiovascular screening and treatment before transplantation, resulting in reduced cardiovascular mortality. Furthermore, the incidence of fatal infections was low in our study (3.5%), which may be due to rapid steroid withdrawal. The rates of fatal infections in studies using steroid-based immunosuppression are much higher (10.5%)47 than those noted in our study. Pretransplant hepatitis B and C in our study were treated to reduce postoperative mortality resulting from hepatic failure.
Our study is most likely the first to report 12-year outcomes in a substantial cohort of kidney transplant patients treated with a new induction protocol comprising low-dose preoperative rituximab and perioperative and postoperative thymoglobulin and steroid-free maintenance immunosuppression along with protocol biopsies. Our study demonstrated excellent short-term and long-term patient and graft survival; the results are significantly better than the figures published in the literature. The all-cause graft failure in our study was better than that noted in the OPTN data published in 2016, wherein most of the kidney transplant recipients were on steroid-based maintenance immunosuppression. Rapid withdrawal of prednisolone lowered the rate of steroid-related side effects and did not increase acute rejection rates and graft loss due to IF/TA. Optimal blood pressure control and reduction in NODAT with our regimen may have beneficial cardiovascular effects. The mortality rate was also low in our study, which could be majorly attributed to mean age of transplant patients, which was lesser in our study compared to general transplant population in other parts of world, the aggressive preoperative cardiovascular screening and treatment. Reduction in death allowed a higher patient and graft survival rate. An aggressive biopsy policy allowed us to identify and treat recurrent glomerulonephritis and thus reduce graft loss, as compared to the published literature.
The use of a systematic steroid-free maintenance immunosuppression strategy including low-dose preoperative rituximab and perioperative and postoperative thymoglobulin induction, tacrolimus–MMF maintenance, use of everolimus in case of tacrolimus toxicity, and the use of protocol biopsies to periodically assess graft function formed the key strength of our study; it allowed us to individualize therapy and optimize survival outcomes.
We acknowledge BioQuest solutions for their editorial services.
1. Starzl TE, Marchioro TL, Waddell WR. The reversal of rejection in human renal homografts with subsequent development of homograft tolerance. Surg Gynecol Obstet. 1963;117:385–395.
2. Luan FL, Steffick DE, Ojo AO. New-onset diabetes mellitus in kidney transplant recipients discharged on steroid-free immunosuppression. Transplantation. 2011;91:334–341.
3. Sureshkumar KK, Hussain SM, Thai NL, et al. Impact of steroid maintenance on the outcomes in first-time deceased donor kidney transplant recipients: analysis by induction type. World J Transplant. 2014;4:188–195.
4. Ticho U, Durst A, Licht A, et al. Steroid-induced glaucoma and cataract in renal transplant recipients. Isr J Med Sci. 1977;13:871–874.
5. Shimmyo A, Miyazaki S, Onoe S, et al. [Ocular complications after renal transplantation]. Nippon Ganka Gakkai Zasshi. 1997;101:220–226.
6. Veenstra DL, Best JH, Hornberger J, et al. Incidence and long-term cost of steroid-related side effects after renal transplantation. Am J Kidney Dis. 1999;33:829–839.
7. Numakura K, Kagaya H, Yamamoto R, et al. Characterization of clinical and genetic risk factors associated with dyslipidemia after kidney transplantation. Dis Markers. 2015;2015:179434.
8. Tejani A, Butt KM, Rajpoot D, et al. Strategies for optimizing growth in children with kidney transplants. Transplantation. 1989;47:229–233.
9. Aroldi A, Tarantino A, Montagnino G, et al. Effects of three immunosuppressive regimens on vertebral bone density in renal transplant recipients: a prospective study. Transplantation. 1997;63:380–386.
10. Sudhagar K, Chandrasekar S, Rao SM, et al. Bone densitometry in post renal transplant patientsIndian J Nephrol. 2001;11:58–60.
11. Ahsan N, Hricik D, Matas A, et al. Prednisone withdrawal in kidney transplant recipients on cyclosporine and mycophenolate mofetil–a prospective randomized study. Steroid withdrawal study group. Transplantation. 1999;68:1865–1874.
12. Vanrenterghem Y, Lebranchu Y, Hené R, et al. Double-blind comparison of two corticosteroid regimens plus mycophenolate mofetil and cyclosporine for prevention of acute renal allograft rejection. Transplantation. 2000;70:1352–1359.
13. Kasiske BL, Chakkera HA, Louis TA, et al. A meta-analysis of immunosuppression withdrawal trials in renal transplantation. J Am Soc Nephrol. 2000;11:1910–1917.
14. Sinclair NR. Low-dose steroid therapy in cyclosporine-treated renal transplant recipients with well-functioning grafts. The Canadian Multicentre Transplant Study Group. CMAJ. 1992;147:645–657.
15. Khwaja K, Asolati M, Harmon J, et al. Outcome at 3 years with a prednisone-free maintenance regimen: a single-center experience with 349 kidney transplant recipients. Am J Transplant. 2004;4:980–987.
16. Borrows R, Loucaidou M, Van Tromp J, et al. Steroid sparing with tacrolimus and mycophenolate mofetil in renal transplantation. Am J Transplant. 2004;4:1845–1851.
17. Matas AJ, Kandaswamy R, Gillingham KJ, et al. Prednisone-free maintenance immunosuppression-a 5-year experience. Am J Transplant. 2005;5:2473–2478.
18. Birkeland SA. Steroid-free immunosuppression in renal transplantation: a long-term follow-up of 100 consecutive patients. Transplantation. 2001;71:1089–1090.
19. Krämer BK, Klinger M, Vítko Š, et al. Tacrolimus-based, steroid-free regimens in renal transplantation: 3-year follow-up of the ATLAS trial. Transplantation. 2012;94:492–498.
20. El-Faramawi M, Rohr N, Jespersen B. Steroid-free immunosuppression after renal transplantation-long-term experience from a single centre. Nephrol Dial Transplant. 2006;21:1966–1973.
21. Suszynski TM, Gillingham KJ, Rizzari MD, et al. Prospective randomized trial of maintenance immunosuppression with rapid discontinuation of prednisone in adult kidney transplantation. Am J Transplant. 2013;13:961–970.
22. Rizzari MD, Suszynski TM, Gillingham KJ, et al. Ten-year outcome after rapid discontinuation of prednisone in adult primary kidney transplantation. Clin J Am Soc Nephrol. 2012;7:494–503.
23. Woodle ES, First MR, Pirsch J, et al; Astellas Corticosteroid Withdrawal Study Group. A prospective, randomized, double-blind, placebo-controlled multicenter trial comparing early (7 day) corticosteroid cessation versus long-term, low-dose corticosteroid therapy. Ann Surg. 2008;248:564–577.
24. Hart A, Smith JM, Skeans MA, et al. OPTN/SRTR 2014 Annual Data ReportAm J Transplant. 2016;16Suppl 211–46.
25. Rush D, Nickerson P, Gough J, et al. Beneficial effects of treatment of early subclinical rejection: a randomized study. J Am Soc Nephrol. 1998;9:2129–2134.
26. Kurtkoti J, Sakhuja V, Sud K, et al. The utility of 1- and 3-month protocol biopsies on renal allograft function: a randomized controlled study. Am J Transplant. 2008;8:317–323.
27. Moon HH, Kim TS, Lee S, et al. Monitoring and treatment for BK virus after kidney transplantation. Transplant Proc. 2013;45:2980–2983.
28. Krejcí K, Tichý T, Hrubý M, et al. Subclinical toxicity of calcineurin inhibitors in repeated protocol biopsies: an independent risk factor for chronic kidney allograft damage. Transpl Int. 2010;23:364–373.
29. Moulin B, Merville P, Renaudin K, et al. Evaluation of protocol biopsy utility 12 months after renal transplantation: a multicenter observational analysis. J Transplant. 2012;2012:781263.
30. Morrissey PE, Reinert S, Yango A, et al. Factors contributing to acute rejection in renal transplantation: the role of noncompliance. Transplant Proc. 2005;37:2044–2047.
31. de Fijter JW, Holdaas H, Øyen O, et al; ELEVATE Study Group. Early conversion from calcineurin inhibitor- to everolimus-based therapy following kidney transplantation: results of the randomized ELEVATE trial. Am J Transplant. 2017;17:1853–1867.
32. Zhao YG, Shi BY, Qian YY, et al. Clinical efficacy of rituximab for acute rejection in kidney transplantation: a meta-analysis. Int Urol Nephrol. 2014;46:1225–1230.
33. Hatakeyama S, Fujita T, Murakami R, et al. Outcome comparison of ABO-incompatible kidney transplantation with low-dose rituximab and ABO-compatible kidney transplantation: a single-center experience. Transplant Proc. 2014;46:445–448.
34. Jain S, Curwood V, White SA, et al. Sub-clinical acute rejection detected using protocol biopsies in patients with delayed graft function. Transpl Int. 2000;13 Suppl 1:S52–S55.
35. Yango A, Gohh R, Wang LJ, et al. The utility of 6-month protocol renal biopsy under modern immunosuppression. Clin Nephrol. 2008;70:490–495.
36. Ortiz F, Gelpi R, Helanterä I, et al. Decreased kidney graft survival in low immunological risk patients showing inflammation in normal protocol biopsies. PLOS One. 2016;11:e0159717.
37. Serón D, Moreso F, Bover J, et al. Early protocol renal allograft biopsies and graft outcome. Kidney Int. 1997;51:310–316.
38. Park WD, Griffin MD, Cornell LD, et al. Fibrosis with inflammation at one year predicts transplant functional decline. J Am Soc Nephrol. 2010;21:1987–1997.
39. Chikaraishi T, Sasaki H, Tsutsumi H, et al. ABO blood type incompatible kidney transplantation without splenectomy prepared with plasma exchange and rituximab. Transplant Proc. 2008;40:3445–3447.
40. Shirakawa H, Ishida H, Shimizu T, et al. The low dose of rituximab in ABO-incompatible kidney transplantation without a splenectomy: a single-center experience. Clin Transplant. 2011;25:878–884.
41. Vieira CA, Agarwal A, Book BK, et al. Rituximab for reduction of anti-HLA antibodies in patients awaiting renal transplantation: 1. Safety, pharmacodynamics, and pharmacokinetics. Transplantation. 2004;77:542–548.
42. Grenha V, Parada B, Ferreira C, et al. Hepatitis B virus, hepatitis C virus, and kidney transplant acute rejection and survival. Transplant Proc. 2015;47:942–945.
43. Lee J, Cho JH, Lee JS, et al. Pretransplant hepatitis B viral infection increases risk of death after kidney transplantation: a multicenter cohort study in Korea. Medicine (Baltimore). 2016;95:e3671.
44. Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med. 2002;347:488–496.
45. Dadhania D, Snopkowski C, Ding R, et al. Epidemiology of BK virus in renal allograft recipients: independent risk factors for BK virus replication. Transplantation. 2008;86:521–528.
46. Knight SR, Morris PJ. Steroid avoidance or withdrawal after renal transplantation increases the risk of acute rejection but decreases cardiovascular risk. A meta-analysis. Transplantation. 2010;89:1–14.
© 2019 The Authors. Published by Wolters Kluwer Health, Inc.
47. Washer GF, Schröter GP, Starzl TE, et al. Causes of death after kidney transplantation. JAMA. 1983;250:49–54.