Lack of early acute rejection does not predict safe tapering of immunosuppression

In an effort to reduce long-term complications of immunosuppressive medications, some investigators have devised protocols of reduced dosage [Kupin et al. 1988, Kelly et al. 1989, Reinsmoen et al. 1993] which are intended to maintain the stability of the transplant and at the same time prevent or retard immunosuppressive medication side effects. Implicit in this plan is the assumption that there has been the development of some degree of graft acceptance [Koene 1989] and/or tolerance [Goulmy et al. 1985, Muluk et al. 1991], yet it is also true that drug non-compliance is a common cause of late acute rejection and graft loss in stable kidney recipients [Rao et al. 1988, Didlake et al. 1988, Rao et al. 1989, Hricik et al. 1991]. The latter fact is a warning that immunosuppression should be cautiously and gradually reduced. Patients who reject grafts early tend to require more immunosuppression. It is not known, however, whether patients who do not reject early require less immunosuppression. Herein, we present a case of late acute cellular and vascular rejection that occurred 9 years after stable renal graft function, in the absence of early acute rejection episodes. This case provides evidence to support the notion that lack of early acute rejection may not predict safe reduction of immunosuppression therapy.