THE RELATION BETWEEN ACUTE VASCULAR AND INTERSTITIAL RENAL-ALLOGRAFT REJECTION AND SUBSEQUENT CHRONIC REJECTION

Chronic rejection of renal allografts is a major cause of late graft l oss. However, time of onset, relation with acute early rejection episo des, and risk factors are largely unknown. We undertook a cohort study of 482 consecutive patients from a single center who received a cadav eric renal allograft between January 1983 and April 1991. During the f irst 3 months after transplantation, 76 (15.8%) patients developed vas cular rejection and 115 (23.9%) developed interstitial rejection. One- year graft survival of patients without rejection, with interstitial r ejection, and with vascular rejection was 87.8%, 87%, and 48.7%, respe ctively, Five-year graft survival was 73.5% for the group without reje ction, 71.4% for patients with interstitial rejection, and 34.3% for p atients with vascular rejection, The adjusted relative risk of graft l oss was 4.92 (95% CI 3.25-7.43) for patients with vascular rejection a nd 1.27 (95% CI 0.80-2.02) for patients with interstitial rejection co mpared with patients without early rejection, taking the time dependen cy of the rejection events and prognostic factors into account. The in cidence of vascular rejection was increased in patients with primary n onfunction (RR 1.69, 95% CI 1.01-2.84), with 1 HLA-DR mismatch (RR 2.3 8, 95% CI 1.44-3.93), with 2 HLA-DR mismatches (RR 3.24, 95% CI 1.25-8 .42), with a prolonged cold ischemia time (RR 1.03, 95% CI 1.00-1.06 p er hr), and with 1 or more previous transplantations (RR 1.76, 95% CI 1.01-3.07). Risk of developing vascular rejection was decreased in pat ients using CsA as compared with azathioprine (RR 0.41, 95% CI 0.24-0. 67). Early vascular rejection, occurring within 3 months after transpl antation, is the most important predicting variable of both early and late graft loss. Use of CsA, less HLA-DR mismatching, and a cold ische mia time of short duration possibly prevent the development of vascula r rejection.