Kidney Week

Abstract: FR-PO881

Does Non-Adherence Predict the Futile Treatment of Severe Acute Kidney Transplant Rejection?

Session Information

• Transplantation: Translational and Transplant Pathology
  October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Transplantation

• 1802 Transplantation: Clinical

Authors

• Al-Sheyyab, Ahmed, Vanderbilt University Medical Center, Nashville, Tennessee, United States

Ahmed Al-Sheyyab,

• Binari, Laura, Vanderbilt University Medical Center, Nashville, Tennessee, United States

Laura Binari,

• Kapp, Meghan E., Vanderbilt University Medical Center, Nashville, Tennessee, United States

Meghan E. Kapp,

• Bala, Stefanie, Vanderbilt.University Medical Center, Nashville, Tennessee, United States

Stefanie Bala,

• Wilson, Nikita, Vanderbilt University Medical Center, Nashville, Tennessee, United States

Nikita Wilson,

• Concepcion, Beatrice P., Vanderbilt University Medical Center, Nashville, Tennessee, United States

Beatrice P. Concepcion,

Background

To treat or not to treat-- that is the question a clinician faces when a patient presents with renal failure in the setting of non-adherence and is found to have acute rejection. Potent rejection therapy, with its associated risks and cost, should arguably be withheld if treatment is to be futile. In this study we aimed to identify clinico-pathologic characteristics, with particular interest on non-adherence, that are associated with futile treatment. We defined futile treatment as graft loss occurring within 6 mos of acute rejection treatment.

Methods

The study included patients >=18y with biopsy-proven acute rejection and received maximal rejection therapy with a lymphocyte-depleting agent, with/without AMR treatment. Patient/transplant characteristics, adherence status and outcomes were collected via chart review. Descriptive statistics were utilized to compare groups. The outcome was all-cause graft loss within 6 mos of acute rejection treatment. Multivariable poisson regression with robust variance analysis was utilized to quantify the association of predictors with the outcome.

Results

115 patients were included in the study, 46% of which were non-adherent. Non-adherent patients were younger (36 vs 46 y), more likely to be on steroid withdrawal (32 vs 16%), attained a lower nadir SCr (1.2 vs 1.8 mg/dL) and rejected later (65 vs 19 mos from transplant). There was no difference in eGFR at presentation or Banff grade on biopsy. Overall, 31% of patients lost their grafts within 6 mos of acute rejection, with a higher percentage in the non-adherent group (42% vs 23%, p=0.03). In adjusted analysis, non-adherent patients had an increased RR of graft loss within 6 mos of acute rejection (RR 1.9, p<0.01). Other predictors of futile treatment included eGFR <=10 at presentation and >5% interstitial fibrosis on biopsy. Age, race, Banff grade, presence of concomitant AMR and type of lymphocyte depleting agent used were not significantly associated with the outcome.

Conclusion

Patients who are non-adherent are at 2-fold higher risk for futile treatment of acute rejection despite lymphocyte depletion. Other risk factors include severe renal dysfunction on presentation and the presence of interstitial fibrosis. In such patients, withholding potent rejection therapy should be considered, and ESRD planning should be initiated.