TRANSPLANTATION 2

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Introduction and Aims: T-cell-mediated rejection (TCMR) commonly complicates kidney transplantation (KT).Antibody-mediated rejection (AMR) is less common, but both are known to shorten graft survival.We sought to quantify the effect of developing both types of rejection (including concurrently) in the first year post-transplant on graft survival.Methods: We performed a retrospective, observational study of kidney-only transplants from our center from 2000-2012.We evaluated patients for biopsy-proven TCMR and/or AMR in the first year post-transplant.Rejection diagnosis was based on biopsy, clinical, and immunogenetic data, consistent with Banff Criteria.AMR diagnosis was based on 2013 Banff Criteria and included C4d-negative AMR.Patients without biopsies were considered rejection-free.Patients were grouped according to their highest level of rejection in the first year.Death and graft failure ascertainment were augmented through linkage to the Scientific Registry of Transplant Recipients.Patient and graft survival were estimated using the Kaplan-Meier method and compared between groups using log-rank testing and Cox models.Results: 5164 biopsies on 1797 patients were performed.Adding patients without biopsies, our study population consisted of 2448 patients.1625, 222, 337, 45, 59, 35, 110, and 15 patients had no rejection, TCMR I, TCMR II, TCMR III, AMR, AMR+ TCMR I, AMR+TCMR II, and AMR+TCMR III, respectively.The majority of AMR patients were HLA-incompatible with their donor and they tended to be female.Death-censored graft loss was generally worse with increasing grade of rejection, with concurrent TCMR and AMR being particularly bad (P<0.001).In a multivariate Cox model, all forms of rejection were significant predictors of graft loss, particularly TCMR III and AMR+TCMR III.All forms of AMR had a hazard of graft loss greater than 3.50.In a a similar adjusted model of mortality, TCMR I (1.48; 95% CI: 1.10-2.00;P=0.009), TCMR II (1.49; 95% CI: 1.18-1.88;P=0.001), AMR (2.70; 95% CI: 1.52-4.81;P=0.001), AMR+TCMR II (1.69; 95% CI: 1.03-2.79;P=0.038), and AMR+TCMR III (2.53; 95% CI: 1.02-6.25;P=0.044) were all significant predictors of death.Conclusions: Rejection of all types is associated with worse graft outcomes, even after adjusting for donor and recipient factors, most strikingly, in TCMR III and AMR+ TCMR III.TCMR I and II, AMR, and AMR+TCMR II were also associated with increased risk of death.The frequencies with which these complications occur highlight the need for enhanced prevention and treatment strategies.

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