ARTIcle Risk Factors for Steroid-Resistant T-Cell–Mediated Acute Cellular Rejection and Their Effect on Kidney Graft and Patient Outcome Waleed Awadain, 1 Osama Gheith, 1 Ahmed Hassan, 2 Nabil Hassan, 1 Salem El-Deeb, 2 Amjad el-Agroudy, 1 Ashraf Fouda, 1 Mohamed Ahmed Ghoneim 1 Abstract Objectives: Acute rejection in renal transplant is considered a risk factor for short-term and long-term allograft survival. The expected reversal rate for the first acute cellular rejection, by steroid pulse, ranges between 60% and 100%, and lack of improvement within 1 week of treatment is defined as steroid- resistant rejection. This work sought to evaluate factors that lead to steroid-resistant acute cellular rejection among patients with first live-donor renal allotransplant and its effect on graft and patient survival. Materials and Methods: Patients with an improvement in serum creatinine levels were considered controls (group 1; n=100); while the others were considered an early steroid-resistant group (group 2; n=99). Both groups were matched demographically. Results: Patients with a target cyclosporine level below accepted therapeutic levels were significantly higher in group 2 (P = .02). We found no significant differences between the groups regarding posttransplant complications (P > .05). Mean hospital stay was longer in group 2 (P = .021). Living patients with functioning graft were more prevalent in group 1, while those alive on dialysis were more prevalent in group 2. The groups were comparable regarding long-term patient and graft survival despite significantly lower creatinine values in patients of group 1 at 6 months’ follow-up (P ≤ .001). Conclusions: Prebiopsy low cyclosporine trough levels and associated chronic changes among patients who were maintained on calcineurin inhibitor-based regimens represented the most-important risk factors for the early steroid-resistant group. Rescue therapies improve short-term graft outcome; however, they did not affect either patient or long-term graft survival after 5 years’ follow-up. Key words: Steroid resistant, Acute rejection, Long-term graft outcome, Risk factors Introduction Renal transplant is the criterion standard for treating-end stage renal disease and has the greatest potential for restoring a healthy and productive life. 1 Immunologic rejection is one of the most-important complications affecting a transplanted kidney. Three major forms of rejection are recognized: hyperacute, acute, and chronic. Each had its own distinctive changes. 2 The most-common form of immunologic rejection in the early posttransplant period is acute cellular rejection, which is mediated predominantly by host lymphocytes responding to the allogeneic donor kidney. Acute rejection typically occurs 5 to 7 days after the transplant, but it could occur at virtually anytime afterwards, with the highest incidence in the first 3 months. Overall rates of rejection varied from 10% to 50% within the first 6 months depending on human leukocyte antigen (HLA) matching and immunosuppressive protocol. 3 Acute rejection in renal transplant is considered a risk factor for short-term and long-term allograft survival. Since the introduction of new immunosuppressive agents, progressive decrease in the incidence of rejection episodes, and subsequent Copyright © Başkent University 2012 Printed in Turkey. All Rights Reserved. From the 1 Urology and Nephrology Center, Mansoura University, Mansoura, Egypt; and the 2 Faculty of Medicine, Zagazeg University, Egypt Corresponding author: Osama A Gheith, MD, Urology & Nephrology Center, Mansoura, Egypt Phone: +965 66641967 Fax: +965 2488815 E-mail: ogheith@yahoo.com Experimental and Clinical Transplantation (2012) 5: 446-453 DOI: 10.6002/ect.2011.0202