8600 Rockville Pike Antibody-mediated rejection and treatment in pediatric patients: one center's experience. Privacy, Help By the end of the first year posttransplantation, 45% of living donor recipients and 60% of cadaver donor recipients will have an episode of rejection. The pericentral (zone 3) parenchyma is necrotic with associated lymphocytic inflammation. Monitoring for acute rejection by using biochemical markers (e.g., troponin and brain natriuretic peptide) or echocardiographic and ECG parameters remains experimental. These pathological features correlated historically with increased graft loss in acute rejection with fibrinoid necrosis of the arteries (type III), with ~25% graft survival at 1 year [20, 21]. Treatment of Antibody-Mediated Rejection After Kidney Transplantation: Immunological Effects, Clinical Response, and Histological Findings. Paediatr Drugs. The differentiation among causes of transplant graft dysfunction can be made most often by percutaneous biopsy with the hazards of inva-siveness. Acute T-cell mediated vascular rejection and acute humoral rejection are less frequent in the first transplant year [2, 3]. The risk of Acute Rejection can be diminished (but not eliminated) with prophylactic immunosuppression. Acute transplantation rejection occurs days to weeks after transplantation. There may be nonspecific symptoms and signs, including fever, malaise, and weight gain. In such a scenario, pre-formed anti-donor antibodies rapidly bind antigens on donor tissue and result in activation of complement or directly recruit host macrophages and neutrophils via their Fc Region. In addition to treating AMR with … doi: 10.12659/AOT.925488. However, graft biopsy can recognize the immune reaction only at its later stages, when allograft injury has already been established. The portal tract contains a mixed inflammatory infiltrate predominantly consisting of lymphocytes and eosinophils. For most organs, the only way to show unequivocally that rejection is occurring is by biopsy of that organ. There is lymphocytic cholangitis . The detection of acute rejection in an early stage is challenging [ 4 ]. Urinary Biomarkers for Diagnosis and Prediction of Acute Kidney Allograft Rejection: A Systematic Review. Lymphocytes from the thymus (t-cells) are blamed for causing acute rejection. Acute rejection is identified clinically by decreased function of the transplanted organ. Copyright © 2020 by the American Society of Nephrology. The difference between hyperacute and acute graft rejection lays in the presence of preformed antibodies that cause rejection immediately. A mixed portal inflammatory cell infiltrate composed of activated-appearing lymphocytes, histiocytes, eosinophils, and other inflammatory cells is typical of acute cellular rejection. Histological features, such as centrilobular necrosis, tend to be more atypical, and initial misdiagnosis occasionally occurs. Polyclonal and monoclonal antibodies for treating acute rejection episodes in kidney transplant recipients. Early Versus Late Acute Antibody-Mediated Rejection Among Renal Transplant Recipients in Terms of Response to Rituximab Therapy: A Single Center Experience. ACR is often treatable, but it still represents an adverse risk factor affecting long-term graft survival. Recipients with borderline changes or SubAR on protocol biopsy are more likely to develop clinical acute rejection and, despite therapy, have higher degrees of interstitial fibrosis and tubular atrophy (IF/TA) and lower allograft survival compared to those with a normal biopsy.61,80–82 However, treatment of SubAR, usually with corticosteroids, is still warranted as it is associated with decreased early and late acute rejection, IF/TA, and better preserved renal allograft function when compared to no treatment.66. acute rejection. It is clinically suspected in patients experiencing an increase in serum creatinine, after the exclusion of other causes of graft dysfunction (generally with biopsy). As shown in Table 39.2, the prevalence of SubAR was much lower in living related renal transplant (LRRT) than in deceased donor renal transplant (DRRT) recipients.61 Cyclosporine had been reported as a risk of SubAR, and some studies conducted in the cyclosporine era demonstrated a higher prevalence of SubAR than studies later conducted when tacrolimus is commonly used. Hyperacute, Acute, and Chronic Rejection Made Simple! Consequently, LAR is frequently associated with a delay in diagnosis, and such delay often results in decreased response to initial steroid treatment. We report a single case of kidney graft rejection of a long-term nonfunctioning graft 14 days after the first cycle of therapy with the PD-1 inhibitor nivolumab. 2017 Feb;15(Suppl 1):150-155. doi: 10.6002/ect.mesot2016.P32. In Diagnostic Pathology: Hepatobiliary and Pancreas (Second Edition), 2017, Need clinical history of chronic viral hepatitis, Both ACR and chronic viral hepatitis exhibit portal inflammation and can show endotheliitis, More mononuclear portal inflammatory cell infiltrate, interface activity, and foci of lobular inflammation favor chronic viral hepatitis, Late ACR can show fewer blastic lymphocytes, less endotheliitis, and more lobular inflammation, More neutrophil-rich portal inflammatory cell infiltrates, bile ductular proliferation, and may show portal edema, Acute cholangitis shows collections of neutrophils within bile duct lumina, De novo or recurrent autoimmune hepatitis usually exhibits numerous plasma cells, more centrilobular perivenular inflammation, and more interface hepatitis, Vast majority are B-cell processes, whereas ACR exhibits mostly T lymphocytes. Urinary obstruction is not the mechanism of oliguria in patients with renal allograft rejection. 2020 Nov 17;25:e925488. - YouTube. Prospective research has shown that SubAR is more common in the early posttransplant period with a prevalence of up to 60% in the first month compared to as low as 18% after 12 months posttransplant.58,59 However, the true prevalence of SubAR is difficult to ascertain given that different definitions are used in different studies, especially with regards to inclusion of borderline change. Acute rejection, detected by surveillance endomyocardial biopsy, is usually clinically silent. A 32-year-old man with a clear and compact graft following a penetrating keratoplasty 6 years back, developed an episode of acute graft rejection, coinciding with the COVID-19 disease. Diagnostics (Basel). Careers. In acute allogra rejection graft, they appear large. Symptoms may include: The organ's function may start to … SHARDA G. SABNIS, ... ZDENA PAVLOVA, in Modern Surgical Pathology (Second Edition), 2009, Acute rejection usually occurs within the first few weeks after transplantation, but it can also occur months or years later, superimposed on chronic rejection or changes. Intravenous steroids and T cell depletion remain the standard therapy for T cell-mediated rejection and are effective in reversing most cases. Acute Cellular Rejection Acute rejection is most common in the first few months following transplantation but can occur at any time during the life of the allograft. Therefore, identification of noninvasive biomarkers capable of identifying early signs of acute rejection represents an area of intense research. See this image and copyright information in PMC. Therefore, it is strongly recommended that acute rejection episodes be treated, unless the treatment is expected to be life-threatening or to cause harm severe enough to preclude treatment. Importantly, patient adherence to therapy should be carefully addressed. If playback doesn't begin shortly, try restarting your device. All recipients have some amount of acute rejection. Graft versus host reaction is an immune condition that occurs immediately after a transplant procedure when the immune cells from the donor attack the recipient patient’s host tissue. Chronic Transplant Rejection occurs months to years after the transplant. For epithelial and subepithelial rejections, which have a higher rate of reversibility, topical corticosteroids can be used six times per day, with a tapered dosing over 6-8 weeks. This case of acute cellular rejection shows a mixed portal infiltrate with a venule showing endotheliitis in the center of the field. Factors predisposing patients to LAR include underlying liver disease, decreased immunosuppression, and poor compliance. Understanding the pre- and post-transplant risk factors for acute rejection can help estimate the probability of immunologic graft damage, and accurate identification of the type and severity of acute rejection will guide appropriate treatment. Cochrane Database Syst Rev. acute rejection of HFP allografts (as early as 4 days post-transplant). de Sousa MV, Gonçalez AC, de Lima Zollner R, Mazzali M. Ann Transplant. If identified early Acute Rejection may be able to be treated with immunosuppressants and corticosteroids. In recent years, with improved immunosuppressive therapy, the incidence of acute rejection is decreasing at a rate of about 8% each year, however, chronic rejection graft loss has increased to 41% of all graft losses in the last 2 years. Of high risk in kidney transplants is rapid clumping, namely agglutination, of red blood cells (RBCs or erythrocytes), as an antibody molecule binds multiple target cells at once. Hyperacute Rejection only occurs if the host possesses pre-formed anti-donor antibody. The exact mechanism is not very well understood but it … Keywords: Acute rejection may occur any time from the first week after the transplant to 3 months afterward. Abuhelaiqa E(1), Friedlander R(2), Aull M(1), Putheti P(1)(2), Sharma V(1)(2), Suthanthiran M(1)(2), Dadhania D(1). 2017 Jul 20;7(7):CD004756. The transplantation of kidney allografts has become a standard therapy for end‐stage renal disease. We use cookies to help provide and enhance our service and tailor content and ads. Subsequent to the infection with the novel coronavirus, he developed symptoms of acute graft rejection concurrent with the development of respiratory distress and peak systemic symptoms. Note the endotheliitis in the lower right corner . Acute cellular rejection (ACR) can be defined as T cell-mediated damage to the liver allograft characterized by cellular infiltrates, principally present in portal areas and associated with damage to bile ducts and vascular structures. For example, one study on a set of 245 urine samples from a pediatric and young adult kidney allograft recipient cohort, identified 35 proteins that could discriminate three types of graft injury, 11 peptides for acute rejection, 12 urinary peptides for chronic allograft nephropathy and 12 peptides for BK virus nephritis . Type of graft rejection: The time period for rejection: Mechanism of rejection: Pathological causes of rejection: Hyperacute rejection: Minutes to hours (may be seen at the table) This is due to preformed antibodies (Humoral) Multiple pregnancies; Repeated blood transfusion; Acute: Days to weeks: Cell-mediated and humoral immune response; There is a primary activation of T-L. Acute cellular rejection is mediated by alloreactive T-lymphocytes that appear in the circulation and infiltrate the allograft through the vascular endothelium. Graft loss from acute and/or chronic rejection was 50% at 1 year and 63% at 3 years, and the median time to graft failure was 4.5 months after biopsy. Bethesda, MD 20894, Copyright Maintenance Immunosuppression . This was the … By continuing you agree to the use of cookies. Histological analysis of graft biopsy is the gold standard technique to diagnose ACR. Symptoms. (2003)Nankivell et al. Published: 05 December 2003; Acute rejection and graft … ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. St. Joseph's Hospital and Medical Center, Phoenix, United States, Leiden University Medical Center - LUMC, Leiden, Netherlands, Universiteit van Amsterdam, Amsterdam, Netherlands, Macsween's Pathology of the Liver (Seventh Edition), Kidney Transplantation, Bioengineering and Regeneration, Diagnostic Pathology: Hepatobiliary and Pancreas (Second Edition), Biomarkers of Kidney Disease (Second Edition), Transplantation of the Liver (Third Edition), Modern Surgical Pathology (Second Edition), Demographics of Pediatric Renal Transplantation, 30% Grade I acute rejection in Banff criteria, OKT3, CsA, or ATG/AZA + steroidsMurine anti-CD3 monoclonal Ab/AZA, CAN at 3 months: LRRT 0% DRRT 25%CAN at 2 years: LRRT 0% DDRT 50%, RCT of protocol Bx(biopsy arm vs control arm), DGF 19% (Biopsy arm) vs 25% (control arm), 1, 2, 3, 6, and 12 months vs 6 and 12 monthsbiopsy arm was treated with corticosteroids, CsA + AZA + PATG or OKT3 were reserved for highly sensitized, At 3 months, Banff chronic nephropathy 24%CAN 20.6%, FK had lower acute score, lower TG, but a similar chronic score, 9. Chronic rejection can take place over many years. Copyright © 2021 Elsevier B.V. or its licensors or contributors. Benjamens S, Moers C, Slart RHJA, Pol RA. Severe episodes of acute rejection can present with arrhythmias, raised jugular venous pressure, hypotension, or echocardiographic evidence of ventricular dysfunction. The immune system can see the grafted organ as foreign and attacks it; destroying it leading to rejection. This process results in leukocyte infiltration of the graft vessel. doi: 10.1002/14651858.CD004756.pub4. Please enable it to take advantage of the complete set of features! Acute cellular rejection T cell-mediated lysis of graft tissue by CTLs, NK cells, and or macrophages ; by cytokine release and inflammation Chronic cellular rejection [09:20] Definition of Acute Rejection. Tissue biopsy remains the gold standard for evaluating immunologic graft damage, and the histologic definition of acute rejection has evolved in recent years. Tissue biopsy remains the gold standard for evaluating immunologic graft damage, and the histologic definition of acute rejection has evolved in recent years. We conclude that acute rejection episodes have a negative impact on the long‐term kidney graft survival in the SKPT population similar to that in the cadaver kidney transplant population. Treatment of symptomatic or histologically severe acute rejection is by means of intravenous corticosteroids and, occasionally, antilymphocytic agents. 2020 Sep 19;21(18):6889. doi: 10.3390/ijms21186889. When compared with AR, LAR appears to be a more virulent form of rejection. This model does not require the establishment of chimerism. After the graft is infiltrated by lymphocytes, the cytotoxic cells specifically target and kill … Accessibility High-dose corticosteroids are the first treatment of acute rejection; they are typically quite effective. Plasma exchange and intravenous Ig, with or without rituximab, are most commonly used for the treatment of antibody-mediated rejection and several newer agents have recently been investigated for severe cases. The portal tract at the left contains a mixed infiltrate. Acute rejection and graft survival in renal transplanted patients with viral diseases Download PDF. This site needs JavaScript to work properly. Acute rejection is more frequent in children than in adults. Endotheliitis is characterized by inflammation of the vein wall and associated endothelial cell lifting . 2020 Dec 30;11(1):47. doi: 10.3390/diagnostics11010047. Indications to pursue graft biopsy over concern for acute rejection include either an acute, otherwise unexplained deterioration in graft function or the presence of a biomarker consistent with acute rejection. Guzzi F, Cirillo L, Buti E, Becherucci F, Errichiello C, Roperto RM, Hunter JP, Romagnani P. Int J Mol Sci. Peter Ruygrok, Andrew McKee, in Cardiothoracic Critical Care, 2007. Zheng J, Xue W, Qing X, Jing X, Hou J, Tian X, Guo Q, He X, Cai J. Gulleroglu K, Baskin E, Bayrakci US, Turan M, Ozdemir BH, Moray G, Karakayali H, Haberal M. Exp Clin Transplant. 2013 Oct;11(5):404-7. doi: 10.6002/ect.2012.0242. (2004), Prospective nonrandomized protocol kidney biopsies, At KTx, 1, 2 week, 1, 3, 6, 12 months, yearly until 10 years), SubAR 60.8%, 45.7%, 25.8%, and 17.7% of biopsies at 1, 3, 12, and > 12 months, Chronic interstitial fibrosis (CIF): substantially occurred within 1 year (67.6%) with maximal intensity within the first 3 monthsBy 10 years, severe CAN 58.4% with 37.3% glomerulosclerosis, Multicenter, randomized, open label study96, The 1st 3 months, all used CsA and SRL. Acute graft rejection and acute tubular necrosis (ATN) that may result from kidney exposure to prolonged periods of warm ischemia constitute two important causes for early acute graft dysfunction. that untreated acute rejection inevitably results in graft destruction. The key … Acute Rejection, Kidney Allograft Function, and Graft Survival in Patients with Circulating Pre-Transplant IgG Antibodies Directed Against Donor HLA-A, -B, or -C Locus Determined Antigens. The acute Acute Graft Rejection Acute cellular rejection (ACR) can be defined as T cell-mediated damage to the liver allograft characterized by cellular infiltrates, principally present in portal areas and associated with damage to bile ducts and vascular structures. In general, patients with primary graft failure and acute rejection with hemodynamic compromise constitute a high-risk group despite therapy. in the SCID mice, as demonstrated by the lack of detectable human CD45 cells in the peripheral blood of rejecting mice. The current standard in the allograft surveillance relies on regular monitoring for increases in serum creatinine or a decrease in creatinine clearance which then triggers subsequent biopsy. To our knowledge, this is the first case of acute transplant rejection in a previously transplanted anuric patient being on peritoneal dialysis for a long period of time. Acute rejection is a major predictor of interstitial fibrosis/tubular atrophy (IF/TA), formerly called chronic allograft nephropathy, which is responsible for most death-censored graft loss … SubAR represents an early time point on the spectrum of clinical rejection. Nankivell et al. One study showed as few as 50% of treated patients responding to steroids.64. Kidney Transplantation and Diagnostic Imaging: The Early Days and Future Advancements of Transplant Surgery. Clipboard, Search History, and several other advanced features are temporarily unavailable. Initiated by preexisting humoral immunity, hyperacute rejection manifests within minutes after transplant, and if tissue is left implanted brings systemic inflammatory response syndrome. As described in the preceding section, assessment of a patient’s immunologic risk at the time of and after transplant can help further define pretest probability of acute rejection when contemplating the utility of biopsy; however, allograft biopsy … From: Macsween's Pathology of the Liver (Seventh Edition), 2018, Madhav C. Menon, ... Fadi El Salem, in Kidney Transplantation, Bioengineering and Regeneration, 2017. Nevertheless, it should remain high on any differential diagnosis of unexplained graft dysfunction because of the potential negative effect on graft longevity. Thus, ECMO or other temporary mechanical support can be considered as salvage therapy in those with AMR and hemodynamic compromise refractory to medical therapy. Unable to load your collection due to an error, Unable to load your delegates due to an error. Acute rejection, recurrent infections, primary graft dysfunction, HLA mismatch, cytomegalovirus pneumonitis, aspiration, and non-compliance with immunosuppressive therapy are thought to be potential risk factors for this disease . Bronchiolitis obliterans syndrome often presents with non-specific symptoms; in advanced cases, patients may present with dyspnea at rest. Hyperacute, Acute, and Chronic Rejection Made Simple! Immunology and pathology; acute allograft rejection; allografts; antibodies; biopsy; differential diagnosis; graft rejection; humans; immunosuppression; intravenous immunoglobulins; kidney transplantation; longevity; nephrologists; plasma exchange; plasmapheresis; renal transplantation; risk assessment; risk factors; rituximab; t-lymphocytes; transplant recipients. "Acute" rejection generally occurs in the first 6 to 12 months after transplantation. Topical steroids are the primary treatment for acute graft rejection and as post operative prophylactic therapy for high risk transplant recipients. Acute cellular rejection (ACR) is the consequence of an immune response of the host against the kidney graft. FOIA Traditionally, acute renal transplant rejection has been divided into three types 1. hyperacute (minutes-hours, often in the operating room) 1.1. The relative risk (RR) of kidney graft failure was 1.32 when acute rejection involved the kidney graft only, while the RR was 1.53 when the rejection involved both organs. Gheith O, Al-Otaibi T, Halim MA, Mahmoud T, Nair P, Monem MA, Al-Waheeb S, Hassan R, Nampoory N. Exp Clin Transplant. This damaged duct shows loss of nuclear polarity, cytoplasmic vacuolization, and nuclear hyperchromasia. This review aims to provide the general nephrologist caring for transplant recipients with an approach to immunologic risk assessment and a summary of recent advances in the diagnosis and treatment of acute graft rejection. S. Jain PhD, A. Jani MD, in Biomarkers of Kidney Disease (Second Edition), 2017, Genetic Biomarkers of Acute Rejection 348, Toll-Like Receptors and Acute Rejection 356, ELISPOT as a Biomarker of Acute Rejection 364, Platelet Activation and Acute Rejection 365, Serum Markers of Inflammation and Acute Rejection 365, miRNAs as Noninvasive Biomarkers of Acute Rejection 370, B-Cell Activation and Acute Rejection (Tissue Biomarkers as Predictors of Response to Therapy) 372, Flow Cytometry and the Diagnosis of Acute Rejection 375, Proteomic-Based Approaches to Finding Biomarkers of Acute Rejection 376, Alkesh Jani, in Biomarkers of Kidney Disease, 2011, Biomarkers of Acute Rejection (Table 6.2) 244, Genetic biomarkers of acute rejection (Table 6.3) 244, Toll-like receptors (TLRs) and acute rejection 258, ELISPOT as a biomarker of acute rejection 264, Platelet activation and acute rejection 265, Serum markers of inflammation and acute rejection 265, B-cell activation and acute rejection (tissue biomarkers as predictors of response to therapy) 269, Cytokines as biomarkers of acute rejection 270, Urine flow cytometry and the diagnosis of acute rejection 271, Proteomic-based approaches to finding biomarkers of acute rejection 272, Imtiazuddin Shaik, ... Pauline W. Chen, in Transplantation of the Liver (Third Edition), 2015, LAR occurs more than 30 days after liver transplantation and may develop in 15% to 20% of patients. The use of potent immunosuppressive agents for induction and maintenance therapy for liver transplantation has reduced the incidence of acute rejection, which is defined as liver allograft dysfunction associated with specific pathologic changes in the graft. Treatment of LAR generally follows the same algorithm as treatment of AR. The early destruction of grafted or transplanted material, usually beginning a week after implantation. The incidence of acute rejection and the time when it occurs vary with the therapy used for immunosuppression.440 In the 1980s, at least one acute rejection episode occurred in 50% to 60% of renal allograft recipients.441 In the latter part of 1990s, with more potent immunosuppression, acute rejection affected 30% of first cadaver transplants, 27% of living related transplants, and 37% of second transplants.442, Pierre Cochat, Diane Hébert, in Comprehensive Pediatric Nephrology, 2008, Acute rejection is responsible for 13% to 21% of graft failure in children.8,21 The number, the severity, and the response to corticosteroids of acute allograft rejection episodes during the first 6 months post-Tx are a major determinant of long-term graft function and survival.21,26,48,49 However, the use of new immunosuppressive regimens has significantly decreased the rate of initial episodes of rejection.15 Early acute rejection may also increase the risk of patient death, due to opportunistic infections during aggressive antirejection therapy.50 The risk of acute rejection by the end of the first year post-Tx is lower with LD Tx.15, Aneesha A. Shetty, ... Michael Abecassis, in Kidney Transplantation, Bioengineering and Regeneration, 2017, Subclinical acute rejection (SubAR) refers to acute rejection detected from a protocol biopsy in a functionally stable renal allograft. Then randomly, to cont’d CsA vs CsA free, Chronic interstitial and tubular lesion (70% vs 40.9%), Graft survival at 10 years was 95% (no CAN), 82% (renal transplant vasculopathy (RTV)), and 41% (CAN with RTV), SubAR 15% (1A 75%, 1B 24%, 2A minority) /, Basiliximab Day 1 & 4 / CsA + prednisone (MMF for high immunologic risk), CAN gp (multivariate: higher CAN, lower GFR at Bx, more often nephrocalcinosis and acute rejection. Acute rejection episodes can have an impact on long-term graft survival, even among patients who recover. Advances in immunosuppressive therapy have drastically improved acute rejection rates in kidney transplant recipients over the past five decades. The body's constant immune response against the new organ slowly damages the transplanted tissues or organ. 2009;11(6):381-96. doi: 10.2165/11316100-000000000-00000. Treatment of Biopsy-Proven Acute Antibody-Mediated Rejection Using Thymoglobulin (ATG) Monotherapy and a Combination of Rituximab, Intravenous Immunoglobulin, and Plasmapheresis: Lesson Learned from Primary Experience. Would you like email updates of new search results? However, there was no statistically significant difference in the incidence of SubAR between cyclosporine and tacrolimus-based immunosuppression in a randomized controlled trial looking at 2-year protocol biopsies.70 Predictably, HLA mismatch between the donor and the recipient is an important risk factor with HLA-DR mismatched transplantation resulting in a higher prevalence of SubAR than zero mismatched transplants.79, Table 39.2. Prevention and treatment information (HHS). Webster AC, Wu S, Tallapragada K, Park MY, Chapman JR, Carr SJ. Treatment strategies to minimize or prevent chronic allograft dysfunction in pediatric renal transplant recipients: an overview. National Library of Medicine Selected Previously Reported Studies for Transplant Kidney Protocol Biopsy With Subclinical Acute Rejection and Chronic Allograft Changes, DRRT 71% (borderline changes & grade I acute rejection), Acute inflammatory score ≥4 and ↑serum Cr <10%, 43%, 32%, 27%, and 15% (1, 2, 3, 6, and 12 months) in biopsy arm vs - 32%, ↓ 32% (6 m tubulointerstitial score (at 6 months) in biopsy arm, Ac inflame activity with Banff borderline change up to 49%, SubAR 29% (grade 1 acute Banff changes 11 pts and >/=Banff 2 1 pt), CAN progress 40% (at 4 months Bx to 53% at 14 months Bx), Bx 8.2±2.6 days Post-Tx, SCR or acute tubulitis in HLA-DR mismatching, 0 DR 23%, 1 DR 46%, 2 DR 31% DR. Ab, antibody; ATG, antithymocyte globulin; AZA, azathioprine; Bx, biopsy; CAN, chronic allograft nephropathy; CNI, calcineurin inhibitors; CsA, cyclosporine A; DDRT, deceased donor renal transplantation; DGF, delayed graft function; FK, tacrolimus; HLA, human leukocyte antigen; IS, immunosuppression; KTx, kidney transplantation; LRRT, living related renal transplantation; P, prednisone; Pt, patients; RCT, randomized clinical trial; SCr, serum creatinine; SubAR, subclinical acute rejection.
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