Very Long-term Survival of the Transplanted Kidney-Characteristics of Recipients.

BACKGROUND: After kidney transplantation (KTx), donor- and recipient-dependent factors, as well as the immunosuppression protocol, may have an impact long-term graft function. The aim of this retrospective study was to identify and describe recipients from a single center who had their transplanted kidney survive for more than 20 years. METHODS: The database of KTx recipients was searched to find identify patients with a functioning kidney graft for >20 years. Clinical, demographic, and immunologic data were recorded and analyzed. Moreover, the Charlson Comorbidity Index was calculated. RESULTS: We identified 25 patients, with graft survival of 23.9 ± 3.2 years (maximum, 31.5 years), with following characteristics: age at time of transplantation 36.2 ± 11.9 years; median of 4 human leukocyte antigen (HLA) mismatches; low risk of rejection (panel-reactive antibodies [PRA] 0%); and 14 recipients had delayed graft function (DGF) and 9 had a single episode of acute rejection successfully treated with steroid pulses. In 24 cases there was a deceased donor. There was a predominance of males aged <54 years. At 1 year after KTx, serum creatinine was 1.36 ± 0.26 mg/dL. All recipients were given cyclosporine + azathioprine + prednisone as primary immunosuppression. The majority of recipients have continued to visit the clinic on an oupatient basis, with a most recent creatinine average of 1.5 ± 0.82 mg/dL. CONCLUSION: Very long-term kidney graft survival is most likely associated with a low risk of rejection (0% PRA pre-KTx), a relatively weak immunosuppression protocol, and optimal function at 12 months post-KTx.

Impact of immunosuppressive treatment on the cardiovascular system in patients after hand transplantation.

BACKGROUND: Cardiovascular disease is a major cause of mortality in solid organ allograft recipients. Hand transplantation is not a lifesaving procedure, thus the effect of long-term immunosuppression on the cardiovascular system in these patients should be monitored. The aim of this study was to evaluate the morphology and function of heart and blood vessels in patients after hand transplantation. METHODS: The study included 5 patients at ages 32 to 58 years, mean 39 years, who underwent hand transplantation between 2006 and 2010. Immunosuppressive treatment included basiliximab in induction and tacrolimus, mycophenolate mofetil, and prednisone. Cardiac status was assessed by echocardiography (according to the American Society of Echocardiography) and cardiac biomarkers. Blood vessels were estimated by carotid intima-media thickness, pulse wave velocity, and brachial artery flow-mediated dilatation (FMD). The examinations were performed at 28 to 79 (mean 43) months after transplantation. RESULTS: Cardiovascular risk factors were observed in all patients after transplantation: 2 had insulin-dependent diabetes, 3 developed dyslipidemia and hypertension, 2 had chronic kidney disease stage 3. Concentric left ventricular hypertrophy was found in 1 and ventricular concentric remodeling in 4 patients. Impaired diastolic function (E/e' > 8) was observed in 2 patients. The index volume of the left atrium was higher in all patients. The cardiac biomarkers N-terminal pro-brain natriuretic peptide, C-reactive protein, and troponins were within normal range. Carotid intima-media thickness was higher in 1 patient and normal in 4 patients. Arterial stiffness measured by pulse wave velocity was not increased in all patients. Native brachial artery FMD response, an index of endothelium-dependent function, was abnormal in 2 patients, but in the transplanted extremity FMD was abnormal in 4 patients. CONCLUSIONS: Pathologic changes in cardiac structures were found in all patients, but the arterial wall changes and endothelial dysfunction were observed in some patients. Patients after hand transplantation are at higher risk for cardiovascular disease.

Extracorporeal photopheresis as an antirejection prophylaxis in kidney transplant recipients: preliminary results.

Extracorporeal photopheresis (ECP) is considered a promising immunomodulatory therapy of acute allograft rejection in organ transplantation and graft-versus-host disease. Our aim was to investigate the biological responses of 10 patients who underwent kidney transplantation with ECP as prophylactic treatment. They received conventional immunosuppressive therapy plus ECP immediately after transplantation: 12 to 16 applications over the course of 2.5 months. ECP procedures were performed using an automated system for leukocyte separation and photoactivation with methoxsalen. All recipients were followed by estimated glomerular filtration rate (eGFR) and peripheral T, B, natural killer, T-regulatory (Treg) and dendritic cells (DC) counts and phenotypes. An acute rejection episode appeared in one control group recipient. The ECP group showed a positive trend to an higher GFR at months 3 (53±11 vs 47.1±9; P=.17) and 6 (67.5±10 vs 53.6±3; P=.03, Wilcoxon test). An increased percentage of Treg (CD3+ CD4+ CD25+) among the total CD3 cell count (4.9%±1% to 9.4%±15%) as well as inducible Treg (CD3+ CD8+ CD28-) was observed among CD3 cells (3.3%±3% to 11.8%±8%, P=.025) within 3 months of ECP treatment. A significant difference in the percentage of Treg was noted at month 3 (completed ECP) between the ECP and the control groups (9.4%±15% vs 3%±1%; P=.01). Addition of ECP to standard immunosuppression was associated with a significantly higher GFR at 6 months and with a significant increase in natural Treg among CD3 cells.

Application of extracorporeal photopheresis in kidney transplant recipients: technical considerations and procedure tolerance.

BACKGROUND: Extracorporeal photopheresis (ECP) is considered to be a promising immunomodulatory therapy in diseases caused by aberrant T lymphocytes. ECP has been used in patients with graft-versus-host disease and systemic scleroderma as well as in solid organ rejection. Herein we report our experience with 148 ECP procedures performed in 10 kidney transplant recipients (12-19 sessions per patient). In 2 subjects, ECP was introduced because of a steroid-resistant rejection episode, and in 8 as supportive treatment in addition to standard immunosuppression in the first 3 months after transplantation. ECP procedures were performed using the UVAR XTS device (Therakos, Exton, PA), an automated closed system for white blood cell separation and photoactivation (ultraviolet light A) with methoxsalen. RESULTS: Vascular access was arteriovenous fistula (n=99), permanent catheter (n=16), peripheral vein (n=25), or polytetrafluoroethylene graft (n=8). Mean blood flow rate was 35.5±5 mL/min. Single ECP procedures lasted 175.5±35 min (range, 120-277), including photoactivation (33.3±30 min). Treatment volume (buffy coat) was 228.4±34 mL per session. Total fluids administered per session were 449.5±60 mL, and mean heparin dose was 5,979±530 IU. ECP-related side effects were transient hypotonia (n=2), increased body temperature (up to 37.5°C; n=4) and red blood cell loss due to a clotted kit or a technical problem with reinfusion (∼100 mL; n=3). CONCLUSIONS: Vascular access for ECP was established in all transplant recipients, using even peripheral veins. Side effects associated with ECP were fairly tolerable by kidney allograft recipients. Caution must be paid to patients with fluid restriction (∼450 mL saline infusion) or the risk of bleeding due to anticoagulation.

An inconspicuous insect bite as the cause of sepsis in a patient treated with infliximab due to rheumatoid arthritis.

The monoclonal antibody against TNFa (infliximab) suppresses cytokines involved in inflammatory reaction. Consequently, infliximab is a potent agent in treating refractory rheumatoid arthritis (RA). There is also evidence showing beneficial anti-TNFα therapy effect on RA-related amyloidosis AA. TNFα inhibition may, however, lead to leucopenia and, eventually, severe sepsis. We discuss a case of RA with RA-related AA amyloidosis and renal impairment which was refractory to disease-modifying anti-rheumatic drug (DMARD). The treatment led to inflammatory complications of two distinct phases: immediately after drug administration and six weeks later. Both phases were linked to an innocuous skin infection.

Impact of donor-dependent genetic factors on long-term renal graft function.

Our aim was to study the association of donor genetic features with long-term graft function as well as the impact of donor age, gender compatibility, cold ischemia time (CIT), and delayed graft function (DGF). We observed the outcomes of 125 kidney recipients for a minimum of 12 months (mean, 30.9 +/- 13.0 months). Grafts were obtained from 89 donors who underwent profiling for AHSG 1/2, MMP9 -1562C/T, IL6 -174G/C, IL1beta 3954C/T, MTHFR 677C/T, MTHFR 1298A/C, NOS3 -786C/T, and PAI1 4G/5G single-nucleotide polymorphisms (SNPs) using sequence-specific probe (SSP) polymerase chain reaction (PCR) and MPO -463G/A and CRP -390C/T/A with restriction fragment length polymorphism (RFLP) analysis. NOS3 IVa/b VNTR polymorphism was genotyped by gel electrophoresis of the respective PCR-generated DNA fragment. The presence of the aa eNOS genotype was connected with worse graft function. The aa genotype was also linked to acute rejection episodes. The lowest values of glomerular filtration rate (GFR) were displayed by recipients of grafts from donors with homozygotic PAI1 gene 5G polymorphism, linking paradoxically with lower PAI-1 synthesis suggesting that the intensity of proteolysis led to increased alloantigen specificity stimulating alloresponses. Graft function depended significantly on donor age with an influence of gender matching. GFR showed a significant dependence on DGF. Genetic features of the donor influenced long-term graft function. Variant eNOS gene polymorphism, which produced decreased eNOS activity, was linked to worse remote graft function. A similar negative impact was observed in the case of donor PAI1 polymorphism, with the functional consequence of lower gene product synthesis.

Hyperuricemia is a mediator of endothelial dysfunction and inflammation in renal allograft recipients.

BACKGROUND: Hyperuricemia is common in renal transplant recipients treated with calcineurin inhibitors. Uric acid induces glomerular hypertension, microvascular disease, and renal interstitial fibrosis and is an independent risk factor for cardiovascular complications. The mechanisms by which uric acid injures renal allografts and the cardiovascular system remain unclear. OBJECTIVE: To assess the influence of uric acid on biomarkers of endothelial dysfunction and inflammation in renal allograft recipients. PATIENTS AND METHODS: The study included 78 allograft recipients with normal allograft function. Exclusion criteria were abnormal renal function, proteinuria, diabetes mellitus, obesity, and inflammation. Participants were divided into 2 groups: 48 patients with hyperuricemia (mean [SD] uric acid concentration, 7.72 [1.33] mg/dL) and 30 patients with normouricemia (5.48 [0.92] mg/dL; control group). Concentrations of plasma resistin, CD146, and soluble vascular cell adhesion molecule-1 (sVCAM-1), which are markers of endothelial dysfunction and inflammation, were assessed in both groups. No significant differences were noted for patient demographic data including age, sex, cause of renal failure, number of HLA mismatches, delayed graft function, and number of acute rejection episodes. RESULTS: Concentrations of the examined biomarkers were increased in the group with hyperuricemia compared with the control group: plasma resistin, 7.15 (2.42) ng/mL vs 6.29 (2.76) ng/mL; CD146, 389.7 (150.0) microg/mL vs 330 (117) microg/mL; and sVCAM-1, 1126 (371) ng/mL vs 955 (269) ng/mL (P < .03). In addition, resistin correlated significantly with sVCAM-1 (P < .01). CONCLUSIONS: Hyperuricemia mediates endothelial dysfunction and inflammation and via this pathway, possibly contributes to chronic allograft injury and cardiovascular events in renal allograft recipients.

Recipient genetic determinants of inflammatory process and nonstandard atherosclerosis risk factors affect kidney graft function early posttransplantation.

We analyzed the connections between recipient genetic features and 12-month graft function. The gene polymorphisms of myeloperoxidase (MPO), interleukin (IL)-1beta, IL-6, C-reactive protein (CRP), fetuin A, and homocysteine and their gene product concentrations were correlated with 12-month kidney transplant function. The 125 kidney recipients had at least 12 months of follow-up (average, 30.9 +/- 13.0 months). IL6-174G/C, IL1beta 3954C/T, MTHFR 677C/T, MTHFR 1298A/C, AHSG 1/2 SNPs were determined using SSP-polymerase chain reaction (PCR) and MPO-463G/A and CRP- 390C/T/A with RLFP analysis. Enzyme-linked immunosorbent assay (ELISA) was applied to estimate MPO, fetuin A, IL-6, and IL-1beta; FPIA was applied for L-homocysteine concentrations. The highest CRP values were linked to the presence of the TT genotype. We observed a positive correlation of CRP concentrations and GFR. Lower fetuin A concentrations were linked to the 256Ser allele, and higher levels to better graft function. Worse graft function was inversely associated with serum homocysteine concentrations. Two polymorphisms (CRP and fetuin A) showed functional consequences in recipients. None of the examined genetic determinations influenced long-term graft function. Higher values, although still within the normal range of CRP concentrations on the day of transplantation and 3 months thereafter, were related to greater values of eGFR at 12 months, suggesting that the higher intensity of the inflammatory reaction may be a manifestation of more effective healing of an ischemia reperfusion injury. Both homocysteine and fetuin A showed long-term prognostic importance.

The abnormal superficial radial artery does not restrict the successful creation of hemodialysis forearm arteriovenous fistula.

Anatomical variations of the radial artery are of clinical importance in end-stage renal disease patients awaiting creation of native arteriovenous fistula for hemodialysis. As radial-cephalic direct wrist fistula is a vascular access of choice, atypical localization of the distal part of the radial artery may lead to the false assumption of severe atherosclerotic lesions and prevent creation of such an access, despite good vessel conditions and convenient surgical approach. We present 7 patients with radial artery variations. In 5 patients with superficial radial artery, radial-cephalic direct wrist access was created. One patient, due to an anomaly misdiagnosis, had radial-cephalic fistula created on the contra lateral wrist. In the patient with hypoplastic radial artery brachial-basilic upper arm transposition was created.

Possible association of CTLA-4 gene polymorphism with cyclosporine-induced gingival overgrowth in kidney transplant recipients.

T-lymphocytes may play a role in the pathogenesis of inflammatory periodontal diseases and cyclosporine (CsA)-induced gingival overgrowth (GO). The gene encoding CTLA-4 (Cytotoxic T-lymphocyte antigen 4, a molecule influencing T-cell activation), is known to have a single nucleotide polymorphism (SNP) in promoter C>T -318; an exon 1 A>G 49, and a microsatellite dinucleotide repeat polymorphism (AT)(n) in exon 4. The purpose of this study was to analyze the possible influence of polymorphisms of CTLA-4, interleukin (IL)-2, and tumor necrosis factor (TNF)-alpha on GO incidence in eighty two renal transplant recipients. 34 CsA-treated with significant GO (CsAGO+); 22, CsA-treated with no GO (CsAGO-), and 26 tacrolimus (Tac)-treated without GO (TacGO-). The SNPs of CTLA-4 (-318 C>T and +49 A>G), IL-2 (-330T>G), and TNF-alpha (-308 G>A) were determined by SSP-PCR methods. The CTLA-4 (AT)(n) genotype was determined using polymerase chain reaction and fluorescence-based analysis with capillary electrophoresis. Allele frequencies in all patient groups were similar for CTLA-4 -318C>T, IL-2, and TNF-alpha. However, patients with CsAGO+ showed differences from CsAGO- for allele and genotype frequencies in position +49A>G of the CTLA-4 gene. The +49G allele was two times less frequent among CsAGO+ than CsAGO- (P = .0052; P corrected = .008). Slight differences between CsAGO+ and CsAGO- were noticed for the genotype distribution of CTLA-4 (AT)(n) (P = .056). The results suggested that appearance of an adenosine allele(A) in position +49 of the CTLA-4 gene may be a permissive element for CsA-induced GO.

Risk factors for glucose metabolism disorders after kidney transplantation with uneventful course.

A wide range of glucose metabolic disorders (GMDs) often arise after renal transplantation that predispose to graft dysfunction, infections, and cardiovascular disease. This study evaluated the risk factors for GMDs among 50 patients including 30 males and overall mean age 44.9 +/- 12.1 years. All 50 subjects displayed normal glucose tolerance tests pretransplantation and no family history of diabetes. They were selected from the 99 consecutive patients transplanted from April 2005 to January 2006 based upon uneventful posttransplantation course, without rejection episodes or hepatitis C virus (HCV) infections. The study concentrated on risk factors originating during the dialysis period. Even in this selected group, the risk of posttransplant GMD development was high (28%). Patients with GMDs showed significantly worse renal function at 1 month after transplantation (serum creatinine concentration: 1.70 +/- 1.67 mg/dL in the GMD group vs. 1.44 +/- 0.96 mg/dL in the group without GMDs [P = .027] and eGFR, 56.68 +/- 22.70 mL/min/1.73 m(2) versus 71.29 +/- 27.37 mL/min/1.73 m(2), respectively, [(P = .099)]. In a logistic regression model, a statistically significant difference between the groups was shown only for cold ischemia time (P = .037). In the logistic regression model with two independent variables, statistical significance was observed (P = .038) for body mass index at the time of transplantation. In this model, a lower pretransplant serum insulin concentration showed an influence that bordered on significance (P = .074). This study confirmed that the etiology of GMD after kidney transplantation is multifactorial, and at least in part connected with the pre-transplantation period.

Dissecting aneurysm of the thoracic aorta in a patient with nephrotic syndrome and brucellosis.

We report the case of a 61-year-old man with nephrotic syndrome due to glomerulonephritis and chronic brucellosis complicated by dissecting aortic aneurysm. The patient worked as a veterinarian and was diagnosed for chronic but non-active brucellosis with positive serum test for Brucella melitensis in the past. Administration of cyclosporine in combination with low dose prednisone resulted at least in proteinuria reduction and partial remission for 3 years. Dissecting aortic aneurysm was treated by insertion of a stent-graft, that resulted in canalization of blood flow and retraction of aneurysm wall later in the course in our patient.

A new technique for autogenous brachiobasilic upper arm transposition for vascular access for hemodialysis.

PURPOSE: Conventional brachiobasilic fistula creation consists of the mobilization and preparation of the brachial part of the basilic vein along its whole length, the vein transposition on the anterior surface of the arm and anastomosis using the brachial artery. In case of late thrombosis, the reparation of such a fistula is almost impossible. METHODS: To avoid total vein clotting in the case of thrombosis we decided to prepare only a short part of the vein in our method and not to mobilize the other part of the vein. The brachiobasilic fistula with our modification was performed as a two-stage procedure in 18 patients (8 females and 10 males), aged from 37-78 yrs (60 +/- 13.6 yrs). RESULTS: In two patients early thrombosis occurred. The reparation procedure was not performed in two patients (the first patient died due to pneumonia; the second patient did not give his permission for further intervention). In 16 patients brachiobasilic fistula creation was successful. Late thrombotic complications occurred in three patients (in the 3rd, 8th and 12th months). A new successful fistula, a few centimeters proximally to the original one, was per-formed in 2 patients 24hr and in 1 patient 48 hr after fistula clotting. On the following day after the procedure the fistula was ready to be used. The primary, assisted primary and cumulative secondary patency rates after 12 months of follow-up were 74, 89 and 100%, respectively. CONCLUSION: In comparison with standard brachiobasilic techniques our method offers the possibility of a reparation procedure in the case of late thrombosis, which could improve the long-term patency of brachiobasilic fistulas. However, a prospective controlled study is necessary to establish if this new technique is superior to the traditional surgical procedure.

Possible association of cytotoxic T-lymphocyte antigen 4 gene promoter single nucleotide polymorphism with acute rejection of allogeneic kidney transplant.

Cytotoxic T-lymphocyte antigen 4 (CTLA-4) molecule is an important inhibitor of T-lymphocyte response. Polymorphisms in the CTLA-4 gene have been described to be associated with numerous autoimmune diseases. However, similar studies in solid organ transplantation have been scarce. Therefore, we examined the distribution of three single nucleotide dimorphisms, namely, -1147T/C, -318C/T, and +49A/G, in two groups of allogeneic kidney graft recipients: (1) those with at least one acute rejection episode ("rejectors"; n = 38) and (2) those with no signs of acute rejection ("nonrejectors"; n = 53). Allele frequencies in both groups of patients were similar in two positions, -1147T/C and +49A/G. However, rejectors showed slight differences from nonrejectors for allele and genotype frequencies in position -318. The -318T allele was two times less frequent among rejectors than nonrejectors, a difference that was close to statistical significance (P = .039; P corrected = .0583), and may reach it when greater numbers of patients are tested.

Outcome of autogenous fistula construction in hemodialyzed patients over 75 years of age.

BACKGROUND: There are controversies regarding the feasibility of autogenous vascular access creation in elderly hemodialysis (HD) patients. The aim of this retrospective study was to evaluate the results of creating different types of autogenous arteriovenous fistulas (AVFs) in a consecutive series of HD patients over 75 years of age. METHODS: The analysis was performed in 131 patients (65 females, 66 males, average age 79.1 +/- 3.6 years) in whom the creation of an autogenous AVF was considered within a 6-year period (February 1998 to February 2004). Among them, 26.7%were diabetics, 66.3% had hypertension, 30.7% were smokers, and 35.6% were obese. Patient survival and primary and secondary AVF patency were assessed. RESULTS: The survival rates for patients were 94, 88, 66, and 45% at 6 months and at 1, 3, and 5 years, respectively. Successful autogenous AVF formation was finally achieved in 107 patients (81.6%): in 99 patients in the forearm and in 8in the upper arm. A Kaplan-Meier analysis showed primary AVF patency rates of: 74 +/- 4.3% (+/- SE) at 1 month; 70 +/- 4.7% at 6 months; 59 +/- 4.9% at 1 year; 59 +/- 4.9% at 2 years; 59+/- 4.9% at 3 years; 59 +/- 4.9% at 4 years, and 58 +/- 4.9% at 5 years. The secondary patency rates were: 95 +/- 2.0; 92 +/- 2.2; 84 +/- 3.3; 79 +/- 4.0; 72 +/- 4.3; 71 +/- 4.4, and 69 +/- 4.5% in the corresponding periods, respectively. All postoperative complications in 10 patients were treated surgically, if applicable, without endovascular techniques. CONCLUSIONS: By exploiting all suitable types of autogenous AVF it is possible to establish the best form of vascular access even in the majority of elderly patients.

Influence of autologous arteriovenous fistula on the blood supply to the hand in very elderly hemodialyzed patients.

INTRODUCTION: Arteriovenous fistula (AVF) creation for hemodialysis (HD) could predispose to local arterial insufficiency of the hand (steal syndrome). Patients with diabetes mellitus, peripheral arterial disease and elderly patients tend to have a higher risk of hand ischemia. PURPOSE AND METHODS: To estimate the influence of AVF on the blood supply to the hands in the elderly population and to identify steal syndrome cases by non-invasive diagnostics (finger photoplethysmography (PPG), pulse volume recording (PVR), Doppler analysis and pulseoxymetry). The evaluation was carried out in 25 random patients (10 females, 15 males) >75 yrs of age (79.6 +/- 3.87 yrs), whose functioning autologous AVFs had been placed at least 1 month previously. RESULTS: Mean PPG and PVR amplitudes did not differ in statistical analysis (p > 0.05) between hands with and without an AVF. One patient (4%) with end-to-side anastomosis was diagnosed with steal syndrome (typical manifestation confirmed in PPG, Doppler and pulseoxymetry). Two other patients with high brachio-cephalic anastomosis presented subclinical steal syndrome (only low PPG and PVR). CONCLUSIONS: Even in the very elderly, AVF creation should be considered due to a lesser influence on the blood supply to the hands. Non-invasive diagnostics used by us seemed to be useful in identifying steal syndrome after AVF creation.

Biopsy eosinophilia as a predictor of renal graft dysfunction.

AIM: The aim of this research was to assess the impact of eosinophilia in renal biopsy specimens obtained during an acute rejection (AR) episode on the severity and reversibility of rejection and on long-term graft function. MATERIAL: Among 165 renal graft recipients who underwent transplantation (Tx) in 2001 and 2002 whose biopsy specimens revealed AR, 49 with tissue eosinophilia were compared with control group of 48 without this feature. The average biopsy time was 60.6 and 95.8 days, respectively. Biopsies during delayed graft function were performed in 46.9% of patients with eosinophilia and 29% in the control group. The immunosuppressive regimen was based on tacrolimus or cyclosporine. RESULTS: Tissue eosinophilia was observed in 49 of 165 patients (29.6%): 5 patients had eosinophilia <10/mm(2), 31 patients 10-100/mm(2), 13 patients >100mm(2) (3 patients >300/mm(2)). Severity of AR according to Banff score was statistically lower in the control group (P <.002). Patients with tissue eosinophilia who initially received steroid-free treatment presented with significantly higher (P =.02) biopsy/patients index (2.3 vs 1.81) than the total eosinophilic group. Serum creatinine values at 6 and 12 months after transplantation (Tx) were higher among eosinophilic when compared with the control group (2.41 vs 1.82 mg/dL, P <.002; 2.10 vs 1.98 mg/dL, P =.006, respectively). Chronic rejection within the first year occurred in 25% of patients with tissue eosinophilia, and 8.3% of patients in the control group. One-year graft survival rate among patients with tissue eosinophilia was lower compared with the control group (89.8% and 93.7%, respectively). CONCLUSIONS: Biopsy eosinophilia is a negative predictor that indicates a more severe course of AR and a worse response to treatment with the threat of chronic graft dysfunction.