Impact of Early Rejection Treatment on Infection Development in Kidney Transplant Recipients: A Propensity Analysis

The impact of renal allograft rejection treatment on infection development has not been formally defined in the literature.

We conducted a retrospective cohort study of 185 rejection (case) and 185 nonrejection (control) kidney transplant patients treated at our institution from 2014 to 2020 to understand the impact of rejection on infection development. Propensity scoring was used to match cohorts. We collected data for infections within 6 months of rejection for the cases and 18 months posttransplant for controls.

In 370 patients, we identified 466 infections, 297 in the controls, and 169 in the cases. Urinary tract infections (38.9%) and cytomegalovirus viremia (13.7%) were most common. Cumulative incidence of infection between the case and controls was 2.17 (CI 1.54-3.05); p < 0.001. There was no difference in overall survival (HR 0.90, CI 0.49-1.66) or graft survival (HR 1.27, CI 0.74-2.20) between the groups. There was a significant difference in overall survival (HR 2.28, CI 1.14-4.55; p = 0.019) and graft survival (HR 1.98, CI 1.10-3.56; p = 0.023) when patients with infection were compared to those without.

As previously understood, rejection treatment is a risk factor for subsequent infection development. Our data have defined this relationship more clearly. This study is unique, however, in that we found that infections, but not rejection, negatively impacted both overall patient survival and allograft survival, likely due to our institution's robust post-rejection protocols. Clinicians should monitor patients closely for infections in the post-rejection period and have a low threshold to treat these infections while also restarting appropriate prophylaxis.