Background: Due to the complex nature of acute rejection (AR), multiple therapeutic modalities may be employed. The benefit of plasmapheresis (PP) with anti-thymocyte globulin (ATG) for the treatment of antibody-mediated rejection (AMR) and acute cellular rejection (ACR) has been demonstrated. However, the prolonged cell depletion with ATG and antibody removal with PP elicit specific concern in regard to infectious complications.

Methods: This is a single-center, retrospective cohort study of kidney (K) and kidney-pancreas (K/P) recipients treated for combined ACR and AMR with PP and ATG between 1/2002 and 6/2010. Patients (pts) were eligible for inclusion if they were >18 years of age; received a K or K/P transplant; and received PP and ATG during the same hospital admission. Pts were excluded if they received PP and ATG prior to transplant as part of a desensitization protocol but did not experience rejection. The primary outcome is to define the incidence of infectious complications in pts receiving PP and ATG for the treatment of AR within 1 year following treatment completion. Secondary outcomes include an analysis of baseline demographics, AR treatment regimen, ATG induction and rejection doses, and number of PP sessions to determine if these variables influence the incidence of infection.

Results: Infection was observed in 47% (33/70) of pts, with multiple infections present in 73% (24/33) of pts. Diagnosed infections included wound (48.5%), bacteremia (42.4%), urinary tract (24.2%), pneumonia (15.1%), peritonitis (9.1%), CMV viremia (24.2%), and herpes zoster (6.1%). A total of 6 pts died, all had an infection. Age was significantly associated with infection, with a 26% increased risk for each 5-year increase in age [OR = 1.2; CI = (1.01, 1.58)].

Conclusion: Increased age is a predictor of infection in pts receiving PP and ATG for the treatment of AR. Infection-related death can be high in these pts.

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