*Purpose: Subclinical rejection of the renal allograft is known to increase the risk of developing interstitial fibrosis and tubular atrophy which ultimately translates into shortening of allograft survival. Patients diagnosed at our center with borderline rejection on protocol renal allograft biopsy, usually with stable serum creatinine, have been treated for years with intravenous steroids followed by an oral prednisone taper. An alternative successful strategy in a number of patients has been to optimize maintenance immunosuppression. Repeat renal allograft biopsy is done to ensure resolution of borderline changes in all cases. The aim of this case controlled study was to ascertain the effect of steroid treatment on bone mineral density (BMD) in patients with borderline rejection treated with IV steroid due to our concern for potential morbidity and increased risk of mortality associated with fractures from worsening bone mineral density.

*Methods: Only patients who received a living or deceased donor kidney transplant at Mayo Clinic Florida between January, 2012 and December, 2014 who developed biopsy-proven acute borderline cellular rejection treated with steroids were included in the study (n=30 ). The control group was selected from the same time period and had no history of rejection (n=30). It is our practice to perform BMD testing annually at our center. Bone mineral density BMD of the lumbar spine, hip and femoral neck were noted before and after steroids in the treatment group and at similar time intervals in the control group. BMD in the treatment group was compared at baseline and post treatment using Student’s paired t-test,and the change in bone mineral density in the treatment group was compared to the control group using two sample t-test.

*Results: We found statistically significant difference in the BMD at the hip before and after steroid treatment in the treatment group (P = 0.04). No statistically significant change was found in the lumbar spine (P =0.40) or the femur (P= 0.22). The change in BMD in the treatment group versus the control group was also found to be statistically significant for both the hip and the femur (P =0.007 and 0.02 respectively)

*Conclusions: There is statistically significant negative impact of steroids on BMD in patients with borderline cellular rejection treated with intravenous steroids. The greatest risk with worsening bone mineral density is associated fracture of the hip with well documented increased morbidity and mortality. We are in agreement that borderline renal allograft rejection should be actively managed to facilitate long-term allograft outcomes. Up to this point, intravenous steroids have been the mainstay of therapy at our institution for borderline renal allograft rejection. However, based on our findings, augmentation of maintenance immunosuppressive therapy may be a better option for treatment of borderline cellular rejection due to adverse effects on bone mineral density.

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