The Impact of Early Protocol Biopsy in Kidney Transplant

The Impact of Early Protocol Biopsy in Kidney Transplant Recipients Receiving TAC and MMF; a Prospective Observational Study

• The purpose of this study is evaluating the impact of steroid pulse therapy (SPT) on SCR revealed on PB in KT recipients maintained on TAC/MMF and corticosteroid.
• In our institution, since routine protocol biopsies are performed at 2 weeks, 1 year, and 2 years after renal transplantation, it is practically difficult that graft survival is used as an endpoint for randomized controlled trials.
• From a meta-analysis for 31 observational studies , acute rejection was associated with an increased risk of graft loss risk ratios ranged from 1.2 - 10.5. Furthermore, chronic allograft nephropathy and graft survival is strongly correlated with acute rejection episode during the first year after renal transplantation.
• Therefore, the aim of this study is to investigate the effect of early steroid pulse therapy for the reduction of acute rejection episode during the first year after KT in the patients who will show subclinical changes at 2-week protocol biopsy.
• The histological feature at 1 year PB, graft function (represented by serum creatinine level and eGFR) during the 1st year of KT were compared between SCR group and non-SCR group.
• Additional benefits including early detection of polioma BK virus associated nephritis (BKVAN) and relapsed underlying disease are also evaluated.

• All recipients will receive induction therapy with basiliximab or rATG and triple maintenance immunosuppression with TAC/MMF and corticosteroid.
• PB at 2 weeks and 1 year after transplantation will be performed using an 18-gauge needle under ultrasound guidance.
• Patients who will get PB can be the candidate of this study.
• Methylprednisolone 0.5 g daily for 3 days will be administered in patients with SCR.
• Information of enrolled patient including age, sex, height, body weight, serum creatinine level, modality of dialysis, duration of dialysis, panel reactive antibody, donor specific antibody, HLA mismatch, ABO incompatibility and history of previous transplantation will be collected. These data will be safely controlled by the person in charge. Patient name will be changed in to initials and registration number of hospital will be changed into new registration number of this study.
• laboratory tests including WBC, BUN, creatinine, FK level, MPA level, CMV virus DNA load, BK virus DNA load, urine nitrate, urine leukocyte esterase, urine BK virus DNA load, urine culture and chest X-ray will be checked on 14th post-operative day and every month until 1year after KT.
• Enrolled patients will be followed for 1 year and routinely undergo 1-year protocol biopsy.
• Within 1 year follow up period, clinical biopsy is performed when recipients' serum creatinine level raised more than 25% of baseline level.
• The primary end point
• Biopsy proven acute rejection event within 1 year after renal transplantation
• Histologic feature including persistent SCR (the presence of SCR at both 2-week and 1-year protocol biopsy), chronic nephropathy at 1-year protocol biopsy.
• Graft kidney function estimated by serum creatinine level and eGFR
• The incidence of opportunistic infection including pneumonia, urinary tract infection, tuberculosis, fungal infection, and viral infections (such as cytomegalo, polyoma, and parvo-virus) within 1 year
• Secondary end points include effect of early detection of polioma BK virus associated nephritis (BKVAN) and relapsed underlying disease

Inclusion Criteria:

• Age 19 - 70 years.

• The patients who underwent renal transplantation.

• The patients who will show rejection in 2-week protocol biopsy with stable graft function will be included in this study.

  • Stable function is defined as serum creatinine ≤1.5 mg/dl and ≤15% increase in serum creatinine in the 2 weeks before biopsy.

Exclusion Criteria:

• The patients who had clinical uremic symptom within 2 weeks after kidney transplantation..
• The patients who had elevated serum creatinine level more than 1.5mg/dl or 15% compared to previous result.
• The patients' age under 19 years or over 70 years.
• The patients who underwent preoperative desensitization.
• The patients who had multiple organ transplantation.
• The patients who showed an allergic reaction to steroid.
• The patients who had psychologic disease (eg. depression) or history of psychologic medication.
• The patients who did not agree with a consent form.