OKT3 FOR PRIMARY THERAPY OF THE 1ST REJECTION EPISODE IN KIDNEY-TRANSPLANTS

The improvement in one-year graft survival has allowed transplant cent ers to focus on long-term graft survival. A study of 665 primary cadav eric kidney transplants from a single center treated with cyclosporine demonstrated that patients did not develop chronic rejection if there was not an episode of acute rejection. This study is a retrospective review of 314 consecutive kidney transplants from a single center to d etermine if early, aggressive treatment of the first episode of acute rejection will improve graft survival without increasing recipient mor bidity. The course of 314 consecutive kidney transplants performed dur ing a 27-month period (245 CAD and 68 living-related) was studied. Dem ographic characteristics were equivalent between the two groups, and a ll patients received sequential quadruple immunosuppression using ALG and CsA. Patient and graft survivals at 2 years were 89.7% and 84%, re spectively. At least one rejection episode occurred in 41% of the pati ents, one-half within 30 days of transplant. Rejection episodes were t reated by oral prednisone taper, primary ALG or OKT3, or ''rescue' the rapy with ALG or OKT3. Graft survival in the 52 recipients treated wit h OKT3 for primary treatment of first rejection episode was 20% better than the 50 patients treated with PRED (P=0.0847). Comparing the 39 r ecipients of primary CAD kidneys treated with primary OKT3 vs. 38 trea ted with PRED demonstrated a 32% improvement in 2-year graft survival (P=0.033). There was no increase in second rejection episodes in patie nts treated with OKT3. Renal function was equivalent in patients with rejection regardless of type of antirejection therapy used. Of patient s treated for rejection, 22% had symptomatic CMV infections, which wer e divided equally between the two groups. Eighty-two patients received a single course of OKT3, 28 received two courses, and 2 patients rece ived OKT3 three times. Only two patients developed antimurine antibodi es that required abandoning OKT3 for the treatment of rejection. This study clearly demonstrates that the early use of OKT3 as primary treat ment of rejection results in significant improvement of 2-year graft s urvival in recipients of first CAD kidney transplants. There is no inc rease in episodes in CMV in patients treated with OKT3 as primary ther apy and no increase in patient mortality. Early use of OKT3 does not p revent or decrease incidence of subsequent rejection episodes. Renal f unction in surviving grafts is not improved in patients treated with O KT3 vs. PRED. The results of this study suggest that the use of OKT3 f or primary therapy for treatment of first acute rejection episode in k idney recipients will probably decrease the incidence of chronic rejec tion and result in improved long-term graft survival.