Induction therapy in kidney transplant recipients: A consensus statement of Indian Society of Organ Transplantation

Table 4 Relative importance of pretransplant risk factors for acute rejection after kidney transplants[19]

Risk factor	Reason for considering	Importance
Younger recipient age	Stronger immune response	++
Adolescent recipient	Higher risk for nonadherence	+++
Donor age	Older organs: Higher immunogenicity	+
Recipient gender	Males: Fewer rejections	+
Ethnicity	African Americans: Significantly higher risk	+++
Deceased vs living donor	Insignificant differences. DD: Insignificant differences between donation after cardiac vs brain death, or ECD vs SCD	+
Previous-transfusion	low immunologic responder: If unsensitized despite previous transfusion	+
Previous-transplantation	Unsensitized recipient: No significant increase in risk; early loss of previous graft to immunological causes → increased risk of next graft rejection	++1
Previous-pregnancy	Increasing risk with successive pregnancies	++
PRA > 0% (HLA antibodies)	Includes both historic and current PRA level HLA antibodies class I and/or class II	+++
Preformed HLA, DSA (> 500 MFI)	Having no preformed HLA DSA at transplant: Low immunological risk. Low noncytotoxic HLA antibodies level: Intermediate risk. Required de novo HLA DSA posttransplant monitoring	++++
Sensitized patients after desensitization	Increased AMR risk, which may persist after desensitization in DSA-positive patients: Negative cytotoxicity and negative flow cross-match (low risk); flow cross-match (moderate increase in risk); positive cytotoxicity (profound increase in risk)	++/+++
HLA mismatch	Marked and well-documented effect on cellular and antibody-mediated rejection. Particularly pronounced for HLA DR mismatch	+++
CMV1 mismatch	No association between CMV mismatch and acute rejection due to CMV prophylaxis	–
EBV1 mismatch	No effect per se on acute rejection	–
Cold ischemia time	Less important with current shorter ischemic times	+
Delayed graft function	Delayed function may prompt changes to the planned protocol in the first few days posttransplant	+++

¹Important consideration in India due to increased risk[20,21].

AMR: Antibody mediated rejection; AT1: Angiotensin II receptor type 1; CMV: Cytomegalovirus; DSA: Donor-specific antibodies; EBV: Epstein-Barr virus; ECD: Expanded criteria donor; HLA: Human leucocyte antigen; MFI: Mean fluorescence intensity; PRA: Panel reactive antibody; SCD: Standard criteria donor.