Borderline rejection: To treat or not to treat?

Alessandra Palmisano; Marta D'Angelo; Ilaria Gandolfini; Marco Delsante; Giovanni Maria Rossi; Micaela Gentile; Enrico Fiaccadori; Paolo Cravedi; Umberto Maggiore

doi:10.1016/j.trim.2024.102047

Borderline rejection: To treat or not to treat?

Transpl Immunol. 2024 Apr 18:84:102047. doi: 10.1016/j.trim.2024.102047. Online ahead of print.

Authors

Alessandra Palmisano¹, Marta D'Angelo¹, Ilaria Gandolfini¹, Marco Delsante¹, Giovanni Maria Rossi¹, Micaela Gentile¹, Enrico Fiaccadori¹, Paolo Cravedi², Umberto Maggiore³

Affiliations

¹ Department of Medicine and Surgery, University of Parma, Parma, Italy; Nephrology Unit, University Hospital of Parma, Parma, Italy.
² Translational Transplant Research Center and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
³ Department of Medicine and Surgery, University of Parma, Parma, Italy; Nephrology Unit, University Hospital of Parma, Parma, Italy. Electronic address: umberto.maggiore@unipr.it.

PMID: 38641147
DOI: 10.1016/j.trim.2024.102047

Abstract

Introduction: It is unclear whether kidney transplant recipients with a biopsy diagnosis as a "borderline" acute T-cell mediated rejection (TCMR) requires the treatment with intravenous (iv) steroids pulse plus/minus intensification of the maintenance therapy (TRT) in comparison with the simple clinical follow-up (F-UP).

Methods: We retrospectively followed a consecutive series of kidney transplant recipients diagnosed with a borderline acute TCMR at biopsy by surveillance or clinical indication for 12 months and compared TRT and F-UP groups. We evaluated trends in renal function by measuring estimated glomerular filtration rate (eGFR) using multiple regression models. Repeated eGFR measures (REML) were adjusted for potential confounding factors for 12 months. The difference in 12-month eGFR values were observed in the TRT vs F-UP groups, type of biopsy, as well as the surveillance vs. clinical outcomes.

Results: Out of 59 included patients, 37% of them were in the TRT group and remaining 63% in the F-UP group. As expected, the TRT group had, at the time of biopsy, lower eGFR value of 39.0 ml/min/m2 [16.5] in comparison to 49.6 [19.6] ml/min/m² in the F-UP group (P = 0.043), Similarly, the TRT group required more frequent clinical biopsies vs. F-UP group (68% vs. 32%; P = 0.014). However, the TRT group recovered kidney function reaching the eGFR values of the F-UP group at 12 months; the increase being significant only in patients who received indication biopsies (P < 0.001). The estimated adjusted TRT effect on 12-month eGFR change after indication biopsy was improved by +15.8 ml/min/1.73m² (95%CI: +0.1 to +31.4 ml/min/1.73 m2; P = 0.048 by three-way interaction term) compared to the F-UP group.

Conclusion: Our preliminary study supports the indication for the treatment of acute borderline TCMR only in cases with biopsies performed by clinical indication.

Keywords: Indication biopsy; Kidney transplant; Organ transplant; Rejection; Renal; Subclinical rejection; Surveillance biopsy.