Silent acute rejection during prolonged delayed graft function reduces kidney allograft survival

Background. The relationship between the effects of early, silent, acute rejection (AR) and delayed graft function (DGF) on kidney allograft; survival remain controversial, and the role of protocol biopsies during DGF is unclear. We hypothesized that protocol biopsies during DGF would reveal a high incidence of silent AR that may adversely affect long-term allograft survival. Methods. We routinely carried out protocol biopsies in patients requiring dialysis 7 to 10 days posttransplant. We retrospectively examined the extent to which silent AR, diagnosed by protocol biopsies during prolonged DGF, may mediate the adverse effects of DGF on graft survival in 410 consecutive transplants using Cox proportional hazards analysis. Results. By 40 days posttransplant, the cumulative incidence of AR was 57.2% among 65 patients who had a protocol biopsies during DGF, while it was only 15.1% among the 345 who did not need a protocol biopsy. Mild DGF (n = 30) requiring one or two dialysis treatments had no effect on graft survival, but the unadjusted risk ratio (and 95% confidence interval) associated with more prolonged DGF (n = 104) was 3.08 (2.09-4.52, P < 0.0001). The risk for graft failure from AR detected on protocol biopsy was 2.91 (1.60-5.27, P = 0.0004) and was similar to the risk from early AR in patients without DGF, 2.95 (1.72-5.07, P < 0.0001). After taking the effects of AR into account, the risk of graft failure attributable to prolonged DGF was reduced to 1.76 (1.06-2.94, P = 0.0294), suggesting that much of the risk of DGF was because of the risk of AR. Conclusions. Silent AR is common during DGF. Prolonged DGF is associated with reduced graft survival after kidney transplantation, and much of this association can be explained by silent AR. In the absence of data from randomized trials, protocol biopsies and treatment of silent AR during prolonged DGF appear to be warranted.