Early surveillance biopsy utilization and management of pediatric renal allograft acute T cell-mediated rejection in Canadian centers: Observations from the PROBE multicenter cohort study.

Abstract

Early TCMR surveillance with protocol kidney biopsy is used differentially among pediatric kidney transplant centers. Little has been reported about actual center-based differences, and this variability may influence TCMR ascertainment, treatment, and monitoring more broadly. Data from the PROBE multicenter study were used to identify patients from centers conducting ESB or LSIB. ESB was defined as >50% of patients having at least 1 surveillance biopsy in the first 9months. Patients were compared for number of biopsies, rejection episodes, treatment, and follow-up monitoring. A total of 261 biopsies were performed on 97 patients over 1-2years of follow-up. A total of 228 (87%) of biopsies were performed in ESB centers. Compared to LSIB centers, ESB centers had 7-fold more episodes of TCMR diagnosed on any biopsy [0.8±1.2 vs 0.1±0.4; P<.001] and a 3-fold higher rate from indication biopsies [0.3±0.9 vs 0.1±0.3; P=.04]. The proportion of rejection treatment varied based on severity: Banff borderline i1t1 (40%);>i1t1 and<Banff 1A (86%); and≥Banff 1A (100%). Biopsies for follow-up were performed after treatment in 80% of cases (n=28) of rejection almost exclusively at ESB centers, with 17 (61%) showing persistence of TCMR (≥i1t1). Practice variation exists across Canadian pediatric renal transplant centers with ESB centers identifying more episodes of rejection. Additionally, treatment of Banff borderline is not universal and varies with severity regardless of center type. Lastly, follow-up biopsies are performed inconsistently and invariably show persistence of rejection.