Background: DGF complicates approximately 30% of deceased donor (DD) kidney transplants and rarely also occurs following live donor (LD) kidney transplants (KTX). KTX in DGF are prone to superimposed acute rejection (REJ) and such REJ is difficult to diagnose without AGBx since oligo-anuria and progressive rise in serum creatinine are features of both DGF and REJ.

Methods: We retrospectively reviewed all the patients who received KTXs at our institution in the period between January 2008 and December 2011 and experienced DGF. These patients received rabbit antithymocyte globulin (Thymoglobulin-R) induction and tacrolimus, mycophenolate and steroid maintenance immunosuppressive regimen. Our protocol called for serial weekly AGBx during DGF to rule out superimposed REJ. This study aimed to determine the incidence of biopsy-documented REJ during DGF and to identify features that may predict the likelihood of REJ developing during DGF.

Results: Out of 420 patients transplanted during this period, 84 patients experienced DGF and underwent at least one weekly AGBx during DGF. Of these 84 patients, there were 54 (64.28%) males, 44 (52.38%) African Americans, 7 (9.09%) LD recipients. Mean age of these 84 patients was 50 +/- 1.1 years. Only 6 patients (7.14%) had biopsy-proven REJ (5 cellular > Banff 1-A and 1 humoral rejection) and 4 patients (4.76%) had Banff-borderline REJ of uncertain significance but were treated with 3 daily methylprednisolone boluses. The remaining 74 patients (88.09%) had no evidence of rejection documented on biopsies performed during DGF. Forty eight patients had one AGBx, 30 had 2 AGBx, 5 had 3 AGBx and one had 4 AGBx during DGF. Initial analysis has not revealed any risk factors that could have predicted the development of REJ during DGF.

Conclusions: Currently, even with the use of potent induction and maintenance immunosuppressive therapy, there is a small incidence (7.14%) of significant and borderline (4.76%) of biopsy-documented REJ during DGF. Although the likelihood of identifying REJ on serial AGBx during DGF is low, in the absence of identifiable predictive risk factors for REJ, serial AGBx remains an essential tool during DGF.

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