Acute cellular rejection (ACR) remains a major cause of graft dysfunction and loss. There is limited data to provide guidance on optimal treatment strategies stratified by Banff grade for pediatric patients with ACR. This report reviews a large pediatric transplant center's experience with ACR treatments and outcomes.

Materials and Methods: Retrospective analysis identified pediatric kidney recipients (age 1-21 yrs) transplanted from 1/1/07 to 12/31/14 with a diagnosis of biopsy-proven ACR. The primary outcome was the incidence of graft failure and change in estimated glomerular filtration rate (eGFR) following ACR with respect to Banff grade and treatment received.

Results: A total of 205 patients were transplanted during the 8 year time frame, of which 66 received treatment for ACR with either an oral steroid cycle (n=16), intravenous steroid pulse (n=28), or rabbit antithymocyte globulin (rATG) (n=22). There were 24 patients diagnosed with Banff borderline rejection, 15 patients with Banff IA rejection, 10 patients with Banff IB rejection, 14 patients with Banff IIA/B rejection, and 3 patients with Banff III rejection. Non-adherence was prevalent in patients who developed more severe grades of rejection. Patients with more severe Banff grades and those with lower eGFR at time of biopsy were more likely to receive rATG treatment. Overall, eGFR significantly improved at 12 months in patients who received rATG compared to those who received steroids alone (p=0.011). Patients with preserved eGFR and Banff grade IA/B that received steroid treatment only had a decline in eGFR (mean -9 mL/min) by 12 months following treatment. In contrast, those with Banff IA/B rejection that received rATG had improvement or preserved eGFR by 12 months following treatment. Patients treated for Banff II/III rejection had improvement in eGFR with any treatment.

Discussion: This study shares a large pediatric transplant center's experience in utilizing rATG for moderate-to-severe ACR and is the first study that describes renal outcomes following treatment of ACR in pediatric patients stratified according to Banff grade. Children with grade IA/B rejection treated with only pulse steroids had decline in renal function over 12 months, raising questions of whether more aggressive treatment was warranted.

CITATION INFORMATION: Chen J, Liverman R, Garro R, Jernigan S, Winterberg P. A Single Center Retrospective Review of Pediatric Kidney Transplant Outcomes According to Banff Grade and Cellular Rejection Treatment. Am J Transplant. 2017;17 (suppl 3).

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