Minimising the risks of treating acute allograft rejection

The risks of treating allograft rejection are primarily related to high-dose steroid therapy. To determine when the possible benefit of anti-rejection therapy might not justify the risks, we analysed 20 severe rejection (SAR) episodes for indices of reversibility. Prior renal function was similar in all patients. Ccr fell to 10 ml/min or less, but degree of renal dysfunction was not predictive of reversibility, nor were time since transplant, oliguro/anuria, proteinuria, or hypertension. The only consistent finding was that function began to improve in reversible rejection 3.8 +/- 1 days after beginning therapy. Our rejection treatment, based on this finding, is to use gram doses of IV prednisolone, up to three times in five to seven days. Among 41 patients with 45 grafts so treated, there was no fatality or gastrointestinal haemorrhage. Other complications (fistulae and/or infections) were related to total dose and frequency, to intensive therapy during severe renal dysfunction or to urinary leaks. Limitation of the period of high-dose steroid therapy was associated with reduced morbidity and mortality in renal allograft recipients.