Audit of acute rejection in renal allografts

Thomas, Riju Mathew
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Acute graft rejection is acknowledged to have a negative impact on graft survival in renal transplantation. South Africa provides for limited renal transplantation amidst the increasing burden of chronic kidney disease in the local context. Despite this suboptimal provision and limited resources, amongst many other concerns, the role of acute graft rejection on graft survival has not been characterized in the context of South Africa, as well as the African continent. This study is an audit, characterising acute graft rejection diagnosed at the Charlotte Maxeke Johannesburg Academic Hospital over a ten-year period (2003-2012). The study revealed the incidence of acute rejection in renal transplants to be 34.5%, similar to that reported in international studies. The majority of acute rejections occurred within the first year of transplantation (53.8%), which was lower than that reported in other studies, with 40% of patients having recurrence of acute rejection. The main form of rejection diagnosed was acute cellular rejection (predominantly BANFF grades 1A and 1B), followed by Borderline acute cellular rejection, the combination of which comprised the majority (86.9%) of all rejections diagnosed. This population was found to be a male dominant and Black African dominant study group, in keeping with the racial distribution of the dialysis population of South Africa, commonly influenced by treatment-seeking behaviour. Cadaveric donor grafts were engrafted in 77.7% of this population and 77.8% of the population had less than 40% of HLA antigens in common with their donor. Delayed graft function was observed in 22.4% of recipients with a significant association with more severe acute graft rejection. Hypertension was the most dominant primary aetiology leading to chronic kidney disease of native kidneys in this population. Immunosuppressive regimen, including cyclosporin, mycophenolate mofetil and prednisone, was used in 80% of recipients, with 97.6% of recipients on mycophenolate mofetil and prednisone. The five-year survival of grafts developing acute rejection was 61.7%. Graft function deteriorated more dramatically amongst recipients who progressed to graft loss, with recovery of graft function observed to be more prominent amongst recipients with surviving grafts. This study adds to the literature on this topic, and also describes the characteristics and outcomes of this entity.
A research report submitted in partial fulfilment of the requirements for the degree of Master of Medicine to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2019