When Should the Third Renal Transplant Rejection Episode be Treated?

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Abstract
Recent reports cite better survival when repeatedly rejecting renal allografts are removed and patients are returned to hemodialysis. The criteria for graft removal remain undefined, although some reports recommend removing all kidneys undergoing a 3rd rejection. In this series (1968-1973) of 316 patients with technically successful 1st grafts followed 2.5-8 yr, graft survival was inversely related to the number of rejection episodes. Of the kidneys without rejection, 100% are currently functioning or functioned at the time of death compared to 90% with 1 rejection, 67.4% with 2 and 21% with 3. However, 40% of kidneys having 3 rejection episodes functioned longer than 1 yr after treatment of the 3rd rejection episode. In an attempt to determine the predictability of 1 yr graft survival or failure following treatment of the 3rd rejection, a formula was developed that correctly predicted the outcome in 33 of 38 (87%) patients. The formula was based on information available prior to treatment of the 3rd rejection episode, and represents an index of baseline renal function (serum creatinine after the 2nd rejection episode) and 2 indices of the severity of rejection episodes (serum creatinine change between the 1st and 2nd rejection episodes; rapidity of sequential rejection). Following its derivation, the formula was applied to a 2nd group (1974) of 19 patients having had 3 rejection episodes. The formula correctly predicted 1 yr allograft survival or failure following treatment of the 3rd rejection episode in 68% of these patients. A striking finding of this review was a significant difference in current patient survival between those having no rejection episodes (89%) and those having 1 or more rejection episodes (65%) (P < .00001). There was no significantly greater long-term curtailment in survival if more than 1 rejection episode was treated. Patients having 1 rejection episode seemed to die from various causes and at various time periods. Patients dying after 2 or more rejection episodes had an increased incidence of deaths due to bacterial infection.