A randomized study of the efficacy of adjuvant local graft irradiation following renal transplantation

Pancreas irradiation for treatment-resistant acute cellular rejection in a severely immunocompromised pancreas-after-kidney transplant recipient-case report

Treating acute rejection of a pancreas transplant in a severely immunocompromised patient with viral opportunistic infection is challenging due to the balance of rescuing from rejection without worsening the morbidity of infection and prolonging the infection episode. We present a case involving a pancreas-after-kidney transplant in a patient with cytomegalovirus (CMV) high-risk discordance (donor positive/recipient negative) and chronic lymphopenia who developed difficult-to-treat CMV disease approximately 6 months after pancreas transplantation. Following the withdrawal of the antimetabolite due to the persistent CMV DNAemia and lymphopenia, the patient experienced acute pancreas rejection without adequate and sustained response to treatment with steroids and thymoglobulin. Moreover, systemic treatment for rejection resulted in higher CMV replication. Pancreas transplant irradiation was performed 5 months after initial pancreatic enzymes increase, resulting in a decrease of lipase below the normal range for 4 to 6 months thereafter. While pancreatic β cells function appeared to be preserved based on stimulated C-peptide testing, the patient experienced ongoing CMV DNAemia despite the treatment and eventually presented with hyperglycemia and diabetic ketoacidosis requiring insulin initiation. Pancreas allograft irradiation may be an option for the treatment of acute pancreas rejection. Appropriate timing to implement this modality and long-term endocrine outcomes need to be prospectively studied.

Local allograft irradiation as an adjunct for treating severe resistant rejection after liver transplantation in adults

Acute rejection after liver transplantation occurs in one-third of all recipients and can be managed with conventional rejection therapy in the majority of cases. In rare instances, patients with severe acute rejection may be refractory to or have contraindications for conventional therapies. This case series evaluates the role of local allograft irradiation (LAI) as an adjunct for patients with rejection that is refractory to or contraindicated for conventional therapies. Additionally, the literature on the use of radiation therapy for reversing rejection in solid organ transplantation is reviewed. Five patients underwent 9 LAI treatments: 2 had refractory rejection, and 1 each had a malignancy, a concurrent life-threatening infection, and serum sickness with antibody therapy. Conventional rejection therapies included steroids, calcineurin inhibitors, and antithymocyte globulin. LAI consisted of 3 cycles of 1.5 Gy directed toward the liver allograft. Two of the 5 patients remained alive with excellent graft function. Six of the 9 treatments were successful in rescuing the liver allograft (reversing the rejection episode). Treatment success was associated with lower pretreatment serum bilirubin levels and higher pretreatment alanine aminotransferase levels. Compared with patients with immunosuppression-responsive severe acute rejection, those requiring LAI trended toward a later onset of first rejection. In conclusion, local irradiation of liver allografts can be a useful adjunct in patients for whom conventional options have been exhausted or cannot be used. The ability of LAI to reverse allograft dysfunction and promote patient survival appears to be greatest before the onset of severe cholestatic injury.

Local graft irradiation for kidney allograft rejection: a case series and review of the literature

Introduction:

Due to its immunosuppressive properties, local graft irradiation (LGI) has been proposed as a second line therapy for treatment of acute kidney rejection.

Case Presentation:

In this case-series we report 6 patients with biopsy proven acute kidney allograft rejection refractory to conventional antirejection therapy who underwent LGI for treatment of acute rejection at our center. Three of these patients had living donor transplants, 2 had deceased donor transplants, and one had received a simultaneous kidney/pancreas transplant. All patients were treated with anti thymocyte-globulin or muromonab-CD3, and intravenous steroids for initial treatment of rejection. Three patients also received intravenous immunoglobulin. LGI was tried as a last resort and was well tolerated and resulted in either improvement or stabilization of renal function in 5 patients. One patient could not be given the complete course of chemical immunosuppression for treatment of rejection due to concomitant cryptococcal meningitis and was switched to LGI with good short-term response.

Discussion:

Our results suggest that LGI could be considered a second line therapy to the conventional anti-rejection therapy for patients with refractory acute kidney allograft rejection, or for patients who cannot receive systemic immunosuppression due to severe infection.

Radiotherapy for Rejection of Renal Transplant Allografts Refractory to Medical Immunosuppression

OBJECTIVE

To evaluate the outcome and prognostic factors of patients who underwent local graft irradiation for acute renal allograft rejection refractory to modern immunosuppressive medications.

METHODS

From 1996 to 2005, 33 patients received local graft irradiation (LGI), with 3 patients receiving 2 courses of radiation. Graft rejection was diagnosed when a rise in creatinine prompted a renal biopsy that demonstrated acute allograft rejection. Upon failure of medical immunosuppresion to resolve rejection, patients were then referred by the organ transplant team for LGI. The median dose was 800 cGy (range, 600-800 cGy), and was given in 200 cGy fractions generally using AP/PA fields. A retrospective review was conducted to determine dialysis-free survival, defined as the date from initiation of radiation therapy to date of hemodialysis placement, and to analyze potential factors that may predict dialysis free survival.

RESULTS

Median follow-up from date of radiation therapy to date of last follow-up was 25 months (range, 0.9-99.4 months). The median time between allograft transplantation and radiation therapy was 17.8 months. For the entire group of patients, 20.6% were alive with a functioning graft. The median dialysis-free survival for the entire group was 3.8 months. The median dialysis-free survival for those patients not on dialysis at time of irradiation versus those patients on dialysis was significantly different (5.6 versus 0 months, P = 0.02).

CONCLUSION

In renal allograft transplant recipients who experienced acute rejection episodes refractory to modern chemical immunosuppression, LGI was well tolerated and remains a viable salvage treatment option.

Liver allograft radiotherapy to treat rejection in children: efficacy in orthotopic liver transplantation and long-term safety

BACKGROUND

We studied, retrospectively, the efficacy to control rejection and long-term safety of liver allograft radiotherapy (RT) performed in 14 children. Long-term safety data were collected with the prospect of possible use of RT in liver cell transplantation (LCT).

METHODS

Immune suppression included cyclosporine, azathioprine and prednisone. In case of intractable rejection, low-dose allograft RT was administered daily for 3 days, and short-term efficacy was evaluated by liver enzyme assays and histology. The long-term outcome was compared with that of 122 patients undergone transplantation and who had similar treatment, but no RT.

RESULTS

Survival at 15 years was 71.4% vs 69.7% in the comparison group. In the RT group, rejection control was complete in six of 14 children and partial in two, all being alive and well 14-18 years later. Ten of 14 children had follow-up biopsy. Six children had normal histology and four had mild unspecific fibrosis. The long-term follow-up biopsy in the comparison group showed fibrosis in 42 of 85 children. The incidence of complications was similar in both groups.

CONCLUSIONS

This series shows that, such a RT regimen appeared to be efficient and safe as a rescue treatment for acute rejection. Provided that further investigations in animal models show a certain benefit of low-dose irradiation around LCT, such a regimen could be proposed in human liver cell transplant programmes.

Outcome of radiation therapy for renal transplant rejection refractory to chemical immunosuppression

Twenty consecutive patients with kidney graft rejection refractory to chemical immunosuppression were treated with local irradiation to the transplanted renal graft (3 x 1.5 Gy). Ten patients were complete responders (median follow-up: 47 months). Six patients were partial responders and failed after 1-4 months. Four patients did not respond.

Radiation nephropathy

The pronounced radiosensitivity of renal tissue limits the total radiotherapeutic dose that can be applied safely to treatment volumes that include the kidneys. The incidence of clinical radiation nephropathy has increased with the use of total-body irradiation (TBI) in preparation for bone marrow transplantation and as a consequence of radionuclide therapies. The clinical presentation is azotemia, hypertension, and, disproportionately, severe anemia seen several months to years after irradiation that, if untreated, leads to renal failure. Structural features include mesangiolysis, sclerosis, tubular atrophy, and tubulointerstitial scarring. Similar changes are seen in a variety of experimental animal models. The classic view of radiation nephropathy being inevitable, progressive, and untreatable because of DNA damage-mediated cell loss at division has been replaced by a new paradigm in which radiation-induced injury involves not only direct cell kill but also involves complex and dynamic interactions between glomerular, tubular, and interstitial cells. These serve both as autocrine and as paracrine, if not endocrine, targets of biologic mediators that mediate nephron injury and repair. The renin angiotensin system (RAS) clearly is involved; multiple experimental studies have shown that antagonism of the RAS is beneficial, even when not initiated until weeks after irradiation. Recent findings suggest a similar benefit in clinical radiation nephropathy.

Successful treatment of radiation nephropathy with angiotensin II blockade

PURPOSE

The aim of this report is to document the successful treatment of radiation nephropathy.

METHODS

Clinical case report with statistical analysis of evolution of kidney function.

RESULTS

A case of radiation nephropathy was found in a kidney transplant recipient whose kidney transplant had been irradiated with 750 cGy 23 years previously. Use of the angiotensin II blocker, losartan, was associated with significant stabilization of the kidney function.

CONCLUSION

Radiation nephropathy can be successfully treated. Other normal-tissue radiation injuries may also be treatable.

[Role of radiotherapy in benign diseases]

Radiation therapy of benign diseases represent a wide panel of indications. Some indications are clearly identified as treatment of arteriovenous malformations (AVM), hyperthyroid ophtalmopathy, postoperative heterotopic bone formations or keloid scars. Some indications are under evaluation as complications induced by neo-vessels of age-related macular degeneration or coronary restenosis after angioplasty. Some indications remain controversial with poor evidence of efficiency as treatment of bursitis, tendinitis or Dupuytren's disease. Some indications are now obsolete such as warts, or contra-indicated as treatment of infant and children.

Local graft irradiation after failure of modern immunosuppression in acute cellular and vascular graft rejection

PURPOSE

With improved chemical immunosuppressive agents, approximately 90% of rejection episodes can be reversed. However, in situations of failed immunosuppression, graft loss becomes inevitable. Our objective is to assess the efficacy of local graft irradiation (LGI) as an effort of last resort in a contemporary group of patients in whom graft failure to irreversible cellular and vascular rejection is imminent.

METHODS AND MATERIALS

A total of 308 renal transplantations were performed at our institution from 1992 to 1995, and an overall 1-year graft survival rate of 90% has been seen as a result of improvement in chemical immunosuppression. However, 6 patients were referred for LGI when all other measures failed to reverse the rejection crisis. Parameters that were studied in these patients included graft function and postirradiation graft histology.

RESULTS

Irradiation was associated with reversal of the rejection crisis and resulted in documented histological long-term graft survival in 1 of the 6 patients (17%). Two of the six patients (33%) had reversal of the rejection episode based on postirradiation biopsy of the renal allograft. Three of the six patients showed some level of clinical improvement of graft function for varying periods of time. One patient maintained stable allograft function without deterioration and with continued independence from hemodialysis. One recipient died from sepsis despite histologic improvement after irradiation.

CONCLUSIONS

Our impression is that LGI is indicated when all other measures have failed to reverse an acute rejection episode in the transplanted renal allograft. The role of radiation in this setting should be studied further.

Radiation therapy for renal transplant rejection refractory to pulse steroids and OKT3

PURPOSE

To determine the response rate and kidney graft survival following local irradiation to the transplanted renal graft undergoing persistent rejection after medical management including pulse steroids and OKT3. The role of radiation for renal transplant rejection after failure of OKT3 has not been previously reported.

METHODS AND MATERIALS

From July 1, 1988 to July 1, 1994, 72 consecutive patients with kidney graft rejection were treated with local irradiation to the transplanted renal graft following failure of medical management. All patients received pulse steroids and OKT3, an anti-CD3 immunosuppressant. Patients who failed to respond to methylprednisolone and OKT3 therapy were referred for radiation therapy. The median time from the diagnosis of rejection to irradiation was 8 days. All kidney grafts received local graft irradiation to a total of 8 Gy delivered in four daily fractions.

RESULTS

Sixty (83%) patients initially responded to radiotherapy at 7 days after completion of radiotherapy, as defined by a decrease in serum creatinine. Thirty-five responding patients have not experienced a second episode of graft rejection. Overall, 43 (60%) patients have renal graft survival, with a median follow-up of 16 months (range of 6-73 months)>

CONCLUSION

It is concluded that there is a subgroup of kidney graft patients undergoing graft rejection who are refractory to pulse steroids and OKT3 therapy where irradiation may be an effective modality with high rates of response and a moderate rate of graft survival. However, a prospective, randomized trial in these medically refractory patients is needed to ascertain whether these results are clinically significant.