RADIATION-THERAPY FOR RENAL-TRANSPLANT REJECTION REFRACTORY TO PULSE STEROIDS AND OKT3

Purpose: To determine the response rate and kidney graft survival foll owing local irradiation to the transplanted renal graft undergoing per sistent rejection after medical management including pulse steroids an d OKT3. The role of radiation for renal transplant rejection after fai lure of OKT3 has not been previously reported. Methods and Materials: From July 1, 1988 to July 1, 1994, 72 consecutive patients with kidney graft rejection were treated with local irradiation to the transplant ed renal graft following failure of medical management. All patients r eceived pulse steroids and OKT3, an anti-CD3 immunosuppressant. Patien ts who failed to respond to methylprednisolone and OKT3 therapy were r eferred for radiation therapy. The median time from the diagnosis of r ejection to irradiation was 8 days. All kidney grafts received local g raft irradiation to a total of 8 Gy delivered in four daily fractions. Results: Sixty (83%) patients initially responded to radiotherapy at 7 days after completion of radiotherapy, as defined by a decrease in s erum creatinine. Thirty-five responding patients have not experienced a second episode of graft rejection. Overall, 43 (60%) patients have r enal graft survival, with a median follow-up of 16 months (range of 6- 73 months). Conclusion: It is concluded that there is a subgroup of ki dney graft patients undergoing graft rejection who are refractory to p ulse steroids and OKT3 therapy where irradiation may be an effective m odality with high rates of response and a moderate rate of graft survi val. However, a prospective, randomized trial in these medically refra ctory patients is needed to ascertain whether these results are clinic ally significant.