Antithymocyte treatment of steroid-resistant acute rejection in renal transplantation

To evaluate the outcome of early (ER <3 months) and late (LR >3 months) episodes of corticosteroid resistant acute allograft rejection (CRR) treated with anti-thymocyte globulin (ATG) in pediatric renal allograft recipients. Retrospective study of 15 children, mean age 13.2y, who received ATG for the treatment of biopsy proven CRR over a 15 year period. Seven children received ATG for ER (median 26 days post transplantation) and 8 for LR (median 763 days). There was a significant improvement in the 3 month eGFR (70.3 ml/min/1.73m², SD 22.3, p = 0.018) when compared with the value prior to ATG treatment (23.3 ml/min/1.73m², SD 10.2) in the ER group. In the LR group (4 DSA positive) there was no improvement in the eGFR at 3 months (42 ml/min/1.73m², SD 10.5, p = 0.32) when compared with the value prior to ATG (38 ml/min/1.73m², SD 9.7). At final review, eGFR in the ER group was 72.3 ml/min/1.73m² (SD 33) vs. 37.7 ml/min/1.73m² (SD 17.9) in the LR group after a mean follow up of 10.4y and 1.2y, respectively. ATG therapy in CRR is associated with reversal of rejection and excellent graft outcome in children with ER. The benefits remain uncertain in LR, the etiology of which is multifactorial.