Impact of acute rejection therapy on infections and malignancies in renal transplant recipients

Background. Infections and malignancies are important causes of mortality a nd morbidity in renal allograft recipients. Their risk increases with incre asing immunosuppression. Methods. In an attempt to quantitate the increase in the risk of these comp lications in association with antirejection therapy, we reviewed the record s of all renal allograft recipients of our center transplanted during the c yclosporin era. We sub-divided the patients into three groups based on acut e rejection episodes during the first 6 months posttransplant, and the trea tment for acute rejection: those who did not develop AR-group 1 (n=168); th ose who had one or more episodes of acute rejection and were treated with h igh dose corticosteroids -group 2 (n=169); those who in addition to cortico steroids required cytolytics (OKT3,) and/or other drugs-group 3 (n=141). Results. 52% patients in group 1, 71% patients in group 2 and 86% patients in group 3 had one or more episodes of infection during the first 6 months posttransplantation. Relative risk for group 2 and 3 were 1.56 (P=0.0002) a nd 2.98 (P<0.00001), respectively. Infection/patient rates at 6 months were 0.67, 1.23, and 2.79 in groups 1, 2, and 3 respectively. Groups 1 and 2 ha d a similar number of cases with squamous and basal cell carcinoma, however , there were few cases with these malignancies in group 3. No case of lymph oma was seen in group Ii there were four cases in group 2 and nine in group 3, There was no significant difference in patient survival in group 1 and 2, however, patients in group 3 had a reduced patient survival (1 vs. 3 P<0 .001, 2 vs. 3 P=0.067), Graft survival was best in group 1 and worst in gro up 3 (1 vs. 2 P<0.05; 1 vs. 3 P<0.00001; 2 vs. 3 P<0.01), Conclusions. In renal transplant recipients the risk of infections and lymp homa increases with increasing immunosuppression and hence mortality and mo rbidity associated with it. When adding a potent immunosuppressive agent to rescue a kidney one needs to consider the serious and at times fatal side effects given the modest beneficial effect on long-term outcome.