Short and long-term outcome of renal transplant recipients with steroid-resistant acute rejection treated with OKT3

OKT3 is used to rescue steroid-resistant acute rejection and achieve high i nitial reversal rates, but its long-term benefit should be established. We have retrospectively studied the short and long-term outcome in 37 out o f 253 recipients (14.6%), receiving a cadaveric renal transplant between 19 90 and 1996, with steroid-resistant rejection treated with OKT3 (5 mg/24 h, 10 days). We have compared their outcome with that of the patients without steroid-resistant rejection. The groups were comparable for sex and age of donor and recipient, HLA mismatch, cold ischemia, original disease and per centage of recipients with OKT3 prophylaxis treatment and second grafts. Immunosuppresion comprised cyclosporin A, azathioprine and corticosteroids. Acute rejection occurred on average 37.5 (range 4-420) days after transpla ntation. The follow-up period after transplantation was 50.9 +/- 27 (1-92) months. Steroid-resistant rejection was defined as progressive renal dysfun ction with histological evidence of acute rejection unresponsive to 1 gram of prednisolone daily for 3 days. The severity of rejection was graded hist ologically by 2 pathologists, unaware of the clinical state, using the BANF F scale; 20 biopsies were assigned to grade I, 14 to grade II and 3 to grad e III. Short-term otucome. Rejection was reversed in 32 out of 37 patients, but 3 recipients died with functioning grafts: one from CMV disease, one from enc ephalitis and one from EBV associated lymphoma. Long-term outcome. Five recipients lost theirs grafts from chronic rejectio n between 22 and 56 months after transplantation. Morever, two patients die d of stroke at 19 and 60 months. Graft survival was higher (p = 0.005) in p atients without steroid-resistant rejection (92.5% at 1 year, 80.2 at 5 yea rs) than in recipients with rejection (83.7 at 1 year, 52% at 5 years), but patient survival was similar (95 and 90.2% at 1 and 5 years versus 91.5 an d 81.4%). The incidence of CMV disease was higher in the group treated with OKT3 (p = 0,004), but the incidence of lymphoproliferative disorders was s imilar in the too groups. In conclusion, short and long-term benefits are achieved in recipients with steriod-resistant acute rejection treated with OKT3, but graft survival is lower than that in patients without steroid-resistant rejection. The incid ence of CMV disease is increased with OKT3 treatment but there was no signi ficant difference in the patient survival in the two groups.