Incidence of Acute Rejection in Deceased Donor Renal Transplant Patients
The incidence of acute rejection in deceased donor renal transplant patients ranges from 30-45% without modern immunosuppression, but has decreased to approximately 15-25% with contemporary immunosuppressive regimens. 1, 2
Factors Affecting Acute Rejection Rates
Immunosuppressive Regimens
- Basiliximab induction therapy combined with standard immunosuppression shows acute rejection rates of approximately 33-38% within the first 6 months post-transplantation 1
- Triple therapy with mycophenolate mofetil, cyclosporine, and corticosteroids reduces biopsy-proven rejection rates to 17-20% 3
- Tacrolimus-based regimens have demonstrated even lower rates of subclinical rejection (2.6%) at 3 months post-transplant 4
Risk Factors for Higher Rejection Rates
- Deceased donor transplants have significantly higher rejection rates (45.1%) compared to living donor transplants (25%) 2
- HLA mismatches ≥4 increase rejection risk (40.3% vs 23% with ≤3 mismatches) 2
- Delayed graft function or acute tubular necrosis increases rejection risk (39.2% vs 26.3%) 2
- Inadequate immunosuppressant levels, particularly cyclosporine, dramatically increase rejection risk 2
Timing of Acute Rejection
- Early acute rejection typically occurs between 1 week to 1 month post-transplantation 5
- Mean time to rejection is approximately 14.3 days after transplantation 2
- Late acute antibody-mediated rejection can occur months to years after transplantation 6
Types of Acute Rejection
- Early acute antibody-mediated rejection (AMR) occurs primarily in sensitized recipients with donor-specific antibodies at transplantation 6
- Late acute AMR typically presents as mixed cellular and humoral rejection 6
- Subclinical rejection (histologic rejection without graft dysfunction) is less common with modern immunosuppressive regimens 4
Impact of Induction Therapy
- Rabbit antithymocyte globulin (rATG) induction shows lower acute rejection rates compared to basiliximab (15.6% vs 25.5%) in high-risk deceased donor recipients 7
- rATG also reduces the severity of rejection episodes, with fewer cases requiring antibody treatment (1.4% vs 8.0%) 7
Strategies to Reduce Acute Rejection
- Adequate immunosuppressant dosing and therapeutic drug monitoring are critical, as subtherapeutic levels significantly increase rejection risk 2
- Induction therapy with either IL-2 receptor antibodies or antithymocyte globulin is recommended for deceased donor transplants 1, 7
- Triple maintenance immunosuppression (calcineurin inhibitor, antiproliferative agent, and corticosteroids) is standard practice 3
Caveat
When evaluating rejection rates from different studies, it's important to consider the era of transplantation, immunosuppressive protocols used, and the definition of rejection (clinical vs. biopsy-proven). Modern immunosuppressive regimens have significantly reduced acute rejection rates compared to historical data.