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To summarize the experiences in high-risk renal transplant recipients for ketter long-term survival.From April 1991 to December 2008, a total of 921 kidney recipients with high-risk factors were divided into six groups as following: (1) pediatric patients (18 years old) (GI, n = 34); (2) retransplant recipients (GII, n = 169); (3) high sensitized patients (PRA30% or peak PRA50%)(GIII, n = 35); (4) elderly recipients (60 years old) (GIV, n = 297); (5) diabetic patients (GV, n = 112); (6) patients with HBV/HCV infection or HBV/HCV carrier (GVI, n = 274). Each group was compared to a control of 807 recipients without any above risk factor for patient and graft survival at 1, 3 and 5 years. Incidences of acute rejection (AR), chronic rejection (CR) and complication were analyzed and compared respectively between the studied subjects and the control group as well.Compared with the control group, patient/graft survivals were lower in GII, GIII and GVI (all P0.05), GIV had worse patient survival (P0.05); AR and CR incidences were greater in GI and GIII (all P0.05); GIV, GV and GVI had more complications.This study suggests the benefits for long-term outcome in high-immunological risk renal transplant recipients of low acute selection incidence rate, and reduction of complication incidences is the key to long term results for non-immunological high risk recipients.

To explore the effect of KIR/HLA ligand matching which mediates activated or inhibitory signal pathways on acute rejection (AR) after kidney transplantation.HLA and KIR genotype assortments were analyzed in 53 donor/recipient pairs of kidney transplantation. The recipients were divided into AR group (GI, n=19) and stable renal function group (GII, n=34) based on the early graft function. The impact of donor HLA, recipient KIR and distinct KIR/HLA class I ligand combinations on acute rejection after kidney transplantation was studied.No significant differences were found in donor HLA-C1/2, HLA-A3, HLA-A11, or HLA-Bw4 between GI and GII groups. The frequency for KIR2DL2/2DS2 and KIR genotype assortment (AA) of the recipients in GI group were significantly lower than that in GII group (26.3% vs 55.9%, P=0.038; 31.6% vs 67.6%, P=0.011). The incidence of AR was significantly lower in donor HLA-C1/1 than in non-C1/1 (31.6% vs 46.7%, P0.05), and lower in recipient KIR genotype assortment (AA) than in non-AA (20.7% vs 52.2%, P=0.011). A significant higher number of matches for the KIR2DL2/ HLA-C1 and KIR2DL3/HLA-C1 were observed in GII group (P=0.030, P=0.028).Distinct KIR/HLA class I ligand combinations between the donor and recipient (such as KIR2DL2/ HLA-C1 and KIR2DL3/HLA-C1) may reduce the incidence of AR. A good KIR/HLA class I ligand matching will benefit the survival of the renal allograft.

To study the changes in Notch1 expression on peripheral lymphocytes after acute graft rejection after renal transplantation.Twenty renal transplant recipients experiencing acute graft rejection and 20 without acute rejection were enrolled in this study. Flow cytometry was used to detect the expression of Notch1 on peripheral lymphocytes of the patients before operation, at the occurrence of acute rejection and after anti-rejection therapy. The rates of Notch1-positive lymphocytes measured at different time points were compared between the two groups.In patients with acute graft rejection, Notch1 expression at the time of rejection onset was significantly higher than that before operation (t=4.245, P=0.000) and that of patients with graft rejection (t=3.839, P=0.000), and was obviously decreased after anti-rejection therapy (t=3.102, P=0.004). Patients without graft rejection showed no significant changes in Notch1 expression after the transplantation (P=0.409). Notch1 expression was comparable between the recipients receiving Tac therapy and those with CsA therapy (P0.05).Monitoring Notch1 expression on the peripheral lymphocytes after renal transplantation may help in the diagnosis of acute graft rejection and prediction of the effect of an anti-rejection therapy.

To identify the factors responsible for the inter-individual variations in the dosage/concentration of tacrolimus in renal transplant recipients.This study involved renal transplant recipients receiving immunosuppressive therapy with the tacrolimus, mycophenolate and prednisone regimen after the operation. The gender, age, height, body weight, tacrolimus dosage, hormone dosage, diarrhea, blood lipids, liver function, renal function, albumin, and hematocrit of the patients were recorded at different time points, namely in early stage (3, 7, 14, and 30 days postoperatively, 118 cases), at 3 months (103 cases), 6 months (75 cases) and over one year (119 cases) after the operation. The concentrations of tacrolimus and gene polymorphisms at CYP3A5, MDR1 3435, MDR1 2677 and MDR1 1236 were also determined in these patients. Multiple linear regression was used for analysis of these factors with tacrolimus concentration/dosage*body surface area as the independent variable.Patients in early stage following renal transplantation showed rather poor fitting of the stepwise regression model, which increased obviously 3 months after the operation and further increased till reaching a stable level at 6 months. Multiple factors were found to affect tacrolimus concentration/dosage in the early postoperative stage, during which period these factors underwent drastic variations and became stable 3 months later. In terms of pharmacogenomics, the major factors affecting tacrolimus concentration/dosage included MDR1 3435, MDR1 2677 and MDR1 1236 polymorphisms, which vastly varied between the patients early after the operation. Of these polymorphic sites, CYP3A5 produced only minor effects on tacrolimus concentration/dosage, and was not included as an active factor until the stable phase (over 1 year) following the transplantation; MDR1 3435 was found to be the predominant factor affecting tacrolimus metabolism in the stable phase. Age, liver function, albumin and hematocrit were found to be positively correlated to the independent variable tacrolimus concentration/dosage*body surface area, and identified as important factors responsible for the intra-individual variation of tacrolimus dosage/concentration.The variations in the factors affecting tacrolimus dosage/concentration after renal transplantation are consistent with the clinical features of the patients, and these factors vary with the postoperative stages. Pharmacogenomic factors produce the most conspicuous effect on tacrolimus dosage/concentration, and agents that may interfere with tacrolimus metabolism should be avoided after the operation. Age, liver function, albumin and hematocrit are also important factors responsible for the variation of tacrolimus dosage/concentration.

To investigate the etiology and therapy of delayed graft function (DGF) recovery in renal transplant recipients.The clinical data were retrospectively analyzed in 15 renal recipients with DGF. All the 15 patients received hemodialysis along with pulse treatment against acute rejection (AR), or immunosuppressant adjustment, or in situ retransplantation after the resection of the original transplanted kidney according to different etiological factors.Among the 15 patients, 8 developed AR, 5 showed acute renal tubular necrosis (ATN), 1 had grafting-associated renal vein embolism and 1 had acute cyclosporine nephrotoxication. The renal function recovered within 10 to 35 days after transplantation without complication during the follow-up period (0.5-3.0 years).DGF is a common complication after kidney transplantation mainly due to the occurrence of AR and ATN. Good prognosis is expected if etiology-oriented therapy is performed properly and promptly.

To study the value of detection of both preoperative soluble CD30 (sCD30) and hepatocyte growth factor (HGF) level 5 days after transplantation in the diagnosis of acute rejection of renal allograft.Preoperative serum sCD30 levels and HGF level 5 days after transplantation were determined in 65 renal-transplant recipients using enzyme-linked immunosorbent assay. The recipients were divided according to the sCD30 levels positivity. Receiver operating characteristic (ROC) curves were used to assess the value of HGF level on day 5 posttransplantation for diagnosis of acute renal allograft rejection, and the value of combined assay of the sCD30 and HGF levels was also estimated.After transplantation, 26 recipients developed graft rejection and 39 had uneventful recovery without rejection. With the cut-off value of sCD30 of 120 U/ml, the positivity rate of sCD30 was significantly higher in recipients with graft rejection than in those without (61.5% vs 17.9%, P0.05). Recipients with acute rejection showed also significantly higher HGF levels on day 5 posttransplantation than those without rejection (P0.05). ROC curve analysis indicated that HGF levels on day 5 posttransplantation was a good marker for diagnosis of acute renal allograft rejection, and at the cut-off value of 90 ug/L, the diagnostic sensitivity was 84.6% and specificity 76.9%. Evaluation of both the sCD30 and HGF levels significantly enhanced the diagnostic accuracy of acute graft rejection.Combined assay of serum sCD30 and HGF levels offers a useful means for diagnosis of acute renal allograft rejection.

To investigate the dynamics of expression of Toll-like receptor 4 (TLR4), an innate immune molecule, in patients early after renal transplantation and the role thereof in the renal transplantation immunity.Eighteen patients early after renal transplantation were divided into rejection group (n = 3) and non-rejection group (n = 15) according to the rejection episode record within two weeks. 1, 4, and 7 days after transplantation peripheral blood samples were collected. Three-color fluorescent staining flow cytometry was used to detect the expression of TLR4 and CD80 in the CD14 positive monocytes.(1) The expression rates of TLR4 in the monocytes 1, 4, and 7 days after transplantation were (21.38 +/- 16.02)%, (11.81 +/- 8.49)% and (4.15 +/- 3.80)% respectively in the non-rejection group with a downtrend; and the expression rate of TLR4 at the 7th day was significantly lower than those at the 1st and 4th days (both P0.05); the expression rates of TLR4 in the monocytes 1, 4, and 7 days after transplantation were (3.59 +/- 1.18)%, (21.5 +/- 20.54)% and (17.05 +/- 12.92)% respectively in the rejection group, showing an increasing trend, however, without significant differences among any 2 values (all P0.05). (2) The link relative ratio of TLR4 expression of day 4 vs day 1 after renal transplantation in the rejection group was significantly higher than that in the non-rejection group (P0.05). The link relative ratio of TLR4 expression of the day 7 vs day 4 after renal transplantation in the rejection group was significantly higher than that in the non-rejection group (P0.05). One case of the rejection group underwent removal of the graft because of irreversible rejection at day 5 after renal transplantation, in which the TLR4 expression rate was decreased day 7. (3) In the non-rejection group, the expression of CD80 at the days 1, 4, and 7 after transplantation displayed a downtrend, however, without significant differences between any 2 values (all P0.05). In the rejection group, the expression of CD80 1, 4, and 7 days after transplantation were elevated in different degrees, however, without significant differences between any 2 values (all P0.05).The dynamics of expression of TLR4 in the patients early after renal transplantation is accordance with their immune state. The link relative ratio of TLR4 expression in the rejection group is significantly higher than that in the non-rejection group.

To observe the dynamic changes of dendritic cells (DCs) in the renal graft of rats within 72 h after renal transplantation.Using SD rats as the donors and Wistar rats as the recipients, renal transplantation was performed in 30 pairs of rats, with another 5 donor kidneys that were not transplanted serving as the sham operation group. The transplanted kidneys were harvested at 1, 6, 12, 24, 48 and 72 h after recovery of blood circulation, paraffin-embedded and sectioned ,followed by HE staining and immunohistochemical staining for S-100 protein for DC identification. The pathological changes and the DC density per glomerulus in the renal graft were observed with optical microscope.No signs of acute rejection were found in these sections. Few DCs were observed in the sham operation group and in the renal graft 1 h after transplantation. The number of DCs in the renal graft increased with time and reached the maximum 24 h after transplantation followed by gradual decrease.Within 72 h after renal transplantation, the number of DCs in the graft varies following a curve with a single peak. Increased DC density in the graft may result from recipient DC migration into the graft, and accordingly, decreased recipient DC migration results in decrease of DC density in the graft. The pattern of DC number variation in the graft can be helpful to further improve the therapy against graft rejection.

To compare the long-term effect and safety of tacrolimus (FK506) and cyclosporine (CsA) in kidney transplant (KT) recipients carrying hepatitis B Virus(HBV).A total of 109 patients with HBV were randomized into FK506 group (52 cases) and CsA group (57 cases) after KT, and a 2-year-long follow-up of the patients was conducted to record the patient and graft survival, incidence of acute graft rejection and postoperative liver function.The 2-year patient/graft survival was 86.0%/73.7% and 94.2%/90.3% in CsA and FK506 groups, respectively (P0.05), with incidence of acute rejection of 10.5% and 9.6% (P0.05), and rate of abnormal liver function of 26.3% and 15.4% (P0.05), respectively. Eight patients (14.4%) in CsA group required a drug conversion but none in FK506 group. The drug conversion resulted in significant reduction of ALT/AST level from 255.13+/-31.38/201.88+/-21.25 U/L to 31.25+/-11.50/25.13+/-9.68 U/L (P0.01).For HBV-carrying renal transplant recipients, FK506 as the primary choice of immunosuppressant can be more effective and safer than CsA.

To investigate the association between transforming growth factor beta-1 (TGF-beta1) gene polymorphism and chronic allograft nephropathy (CAN).Fifty patients with failed renal allografts and clinically and histopathologically confirmed CAN were enrolled in this study along with another 50 renal transplant recipients with normal graft function. The DNA extracted from whole blood of the patients was amplified with PCR with sequence-specific primers for determining TGF-beta1 genotypes (position +869, codon 10 and position +915, codon 25). According to documented descriptions, the patients were classified into high and moderate-to-low cytokine production genotypes. The distribution frequencies of high production genotypes was then compared between CAN and non-CAN groups. To eliminate interference in the analysis of the association between TGF-beta1 polymorphism and CAN, other possible risk factors for CAN were screened, including the patients' gender, age, HLA match, delayed graft function, acute rejection, immunosuppressive regimen, cytomegalovirus infection, hypertension, and high cholesterol.CAN patients showed significantly greater proportion of high cytokine production genotype than the non-CAN group [70% (35/50) vs 38% (19/50), Chi(2)=10.306, P=0.001). Of the screened risk factors for CAN, only acute rejection showed some difference between the two groups, but analysis after subgrouping according to acute rejection did not suggest its influence on CAN, which supports the result that the rate of high production genotype was significantly higher in CAN group than in the non-CAN group.Most CAN patients have high TGF-beta1 production genotype, which might be a risk factor for CAN after renal transplantation. TGF-beta1 genotyping can be of value in predicting the risk of CAN after renal transplantation.

To investigate the risk factors of transplant renal artery stenosis (TRAS).The clinical records of 26 patients undergoing renal transplantation in our hospital between 2000 and 2005 were retrospectively analyzed, whose final diagnosis of TRAS was established on the basis of arteriographic findings. A case-control group of 52 post-renal transplantation patients were sampled by stratified randomization, whose blood pressure and renal graft function were without complications of avascularity or urinary passage. The two groups were matched for the operation time, gender, age, primary diseases, blood type, PRA and HLA matching and use of immunosuppressants. Possible events related to TRAS such as cold ischemia time, acute rejection, delayed graft function and approaches of arterial anastomosis were compared.Fifteen patients (57.7%) with TRAS had a history of acute rejection episode, 7 (26.9%) had delayed graft function, both rates of which were higher than those in the control group (P0.05). The cold ischemic time and type of arterial anastomosis showed no significant effect on TRAS occurrence (P0.05).Post-transplant renal artery stenosis is closely associated with acute rejection and delayed graft function but not with the cold ischemic time or the type of arterial anastomosis.

To explore the clinical significance of early diagnose and treatment of subclinical renal allograft rejection.Ninety-six renal allograft recipients (54 male and 42 female) with normal renal function aged 17 to 58 years (mean 37.5 years) were included in this study. Early subclinical rejection was diagnosed 3 months after the transplantation by color Doppler examination.Patients with early subclinical rejection were given methylpredisolone followed by adjustment of immunosuppressive regimens, and no difference was observed in 3-year survival rate between these patients and those with normal renal allograft findings.Early diagnosis and treatment of subclinical renal allograft rejection is significant to improve renal allograft survival rate.

To investigate the effect of treatment on end-stage liver disease and type-I diabetes mellitus with simultaneous liver-pancreas-duodenum transplantation.In September 2003, one patient with chronic hepatitis B, liver cirrhosis, hepatic cellular cancer, and insulin-dependent diabetes received simultaneous orthotopic liver and heterotopic pancreas-duodenum transplantation. Liver and pancreas graft function was monitored after transplantation.The function of pancreas allograft was recovered immediately and the patient became insulin-independence postoperatively. The liver allograft was experienced an acute rejection episode and reversed by intravenous bolus methylprednisolone. The recipient was currently liver disease-free and insulin-free more than 21 months.The simultaneous liver-pancreas-duodenum transplantation is an effective method in the treatment of end-stage liver disease and type-I diabetes mellitus.

To detect the expression of CD95 and CD95L mRNAs after liver transplantation and investigate the role of CD95 and CD95L in acute liver allograft rejection.The expressions of CD95 and CD95L mRNAs of peripheral blood lymphocyte from 56 liver allograft recipients were examined using SYBR real-time PCR.CD95 and CD95L mRNA levels in the recipients with acute rejection were significantly higher than those without rejection (P0.01), and the elevation occurred about 2 days earlier than that of alanine aminotransferase and aspartate aminotransferase.CD95 and CD95L are related to acute liver allograft rejection and their mRNA expression level may serve as an indicator for prediction and diagnosis of acute rejection episodes.

To evaluate the correlation between the quality of donor renal grafts and graft rejection.The cold ischemia time and the pathological findings by biopsies of the donor grafts in 87 cases were analyzed in conjunction with the occurrence of acute or chronic graft rejection after transplantation.After transplantation, acute rejection occurred in 28 cases, in which 5 (17.8%) had adverse changes in the donor grafts; chronic allograft nephropathy developed in 13 cases, in which 6 (46.1%) had adverse changes in the donor grafts. By binary logistic regression analysis, the cold ischemia time and acute renal tubular injury were identified as the factors affecting acute graft rejection, and cold ischemia time and glomeruloserosis as the risk factors for chronic rejection.High-quality donor kidney and minimization of the risk factors help reduce the occurrence of graft rejection after kidney transplantation.

To investigate the expressions of transforming growth factor (TGF)-beta1 and collagen IV in the renal tissues of patients with chronic allograft nephropathy (CAN).Immunohistochemical method and computer-assisted image analysis system were used to detect the expressions of TGF-beta1 and collagen IV in the renal tissues of patients with CAN, and the association between TGF-beta1 and collagen IV expressions as well as that between their expressions and the pathological grading of CAN were analyzed.The expressions of TGF-beta1 and collagen IV were significantly higher in the renal tissues of the patients than in normal renal tissues (P0.001), and the expressions tended to increase with the pathological grades of CAN; TGF-beta1 and collagen IV expressions in both the renal glomeruli and the tubulointerstitium were in patients with CAN positively correlated with normal renal tissues (r=0.943, P0.001; r=0.910, P0.001).Abnormal collagen IV deposition is one of the major factors associated with renal fibrosis in CAN, and TGF-beta1 might play an important role in renal fibrosis in CAN through up-regulation of collagen IV in the renal tissues.

To compare the efficacy and safety of tacrolimus (FK506)- versus cyclosporine (CsA)-based immunosuppression protocol in the treatment of patients with renal transplantation for diabetic end-stage renal disease.A total of 64 patients with end-stage renal disease were randomized into FK506 (n=33) and CsA (n=31) group after cadaveric renal transplantation, the former group adopting small-dose FK506 therapy with low trough concentration, and the latter receiving CsA therapy. The dose of insulin was adjusted according to blood glucose level of the patients after the operation. The incidence of acute rejections, blood glucose level, the dose of insulin and changes in blood pressure, lipid metabolism and liver function were compared between the two groups.The 1-year patient/graft survival rates were 96.97%/93.94% in FK506 group and 96.77%/90.32% in CsA group. Four patients (12.12%) developed acute rejection in the FK506 group, while 11 (35.48%) did in the CsA group during the first year after the operation (P0.05). The dose of the insulin of the FK506 group (34.35 U/d, 14.09 U/d) was not significantly different from that in the CsA group (28.15 U/d, 13.05 U/d) at the first month and 1 year after the operation (P0.05). One year after the operation, 21 patients (63.63%) required anti-hypertension treatment, 5 (15.15%) needed anti-hyperlipidemia treatment and 3 (9.09%) had abnormal liver function in FK506 group, while in the CsA group, 28 patients (90.32%) needed anti-hypertension therapy, 13 (41.94%) received anti-hyperlipidemia treatment and 11 (35.48%) showed signs of abnormal liver function, with significant differences between the two groups.Small-dose FK506 therapy with low concentrations is effective in the postoperative management of patients with renal transplantation for diabetic end-stage renal disease, with only mild adverse effect. FK506 is comparable with CsA in terms of the effect on glucose metabolism of the patients.

To study the surgical techniques, perioperative management, management of infections and graft rejection in patients with combined liver-kidney transplantation (CLKT).CLKT was performed in a 66-year-old patient with alcoholic liver cirrhosis and uremia. Lavage in situ with University of Wisconsin (UW) solution of the donor organs and en hoc resection was performed. Orthotopic liver transplantation (OLT) and routine kidney transplantation were respectively carried out. Immunosuppression therapy consisted of tacrolimus (FK506), antithymocyte globulin (ATG), mycophenolate mofetil (CellCept, MMF) and corticosteroid.Both of the transplanted organs rapidly recovered normal functions after operation, and acute rejection of the liver graft occurred on day 10 after operation but was controlled after methylprednisolone pulse therapy. The patient fully recovered and was discharged from hospital on day 29 after operation.CLKT is effective against both liver and renal function failure. Well-matched HLA tissue typing, proficient surgical skills, adequate application of immunosuppressants and effective management of postoperative complications are crucial for successful CLKT.

To explore the possible causes of transplant renal artery stenosis (TRAS) in cadaveric transplant recipients.We retrospectively analyzed multiple factors that may contribute to TRAS (including the patients' age, presence of diabetes, cold ischemic time, acute rejection episode, cytomegalovirus infection, serum cholesterol, LDL cholesterol, pre-operative dialysis, number of donor renal arteries, which side of donor kidney, type of surgical anastomosis, different protocols of inductive and maintenance drug therapy) in 18 recipients with transplant renal artery stenosis after cadveric renal transplantation from Jan. 2000 to Dec. 2001 in comparison with another 566 non-TRAS recipients who underwent the transplantation during the same period.There was a higher incidence of acute rejection in the TRAS group than non-TRAS group (66.67% vs 5.48%, P0.01), and no significant difference was noted between TRAS and non-TRAS cases in terms of the pre-operative dialysis, presence of diabetes, cold ischemic time, number of donor renal arteries, whith side of donor kidney, type of surgical anastomosis, different protocols of inductive and maintenance drug therapy, cytomegalovirus infections and serum and LDL cholesterols.The occurrence of TRAS in cadaveric allografts is associated with acute graft rejection episode, suggesting the importance of the treatment of acute graft rejection in the prevention of TRAS.

To evaluate the role of panel reactive antibody (PRA) screening and human leukocyte antigen (HLA) typing in renal transplantation.PRA screening and HLA typing were performed in 1 700 patients eligible for the first group of renal transplantation who had 3 to 6 HLA matches in HLA-A, B and DR with the donor, and in cases positive for PRA, plasma exchange was conducted. Another 423 patients who did not receive PRA screening or HLA typing constituted the second group. The changes of immune variables, incidences of acute rejection and the effect of HLA-A, B, DR matching on long-term graft survival were observed.In 1 700 cases of group 1, post-transplantation CsA dose was reduced to 5 to 7 mg*kg(-1)*d(-1) and the graft function recovery time ranged from 2 to 16 d, averaging 5 d. Acute graft rejection occurred in 252 (14.8%) cases, but no hyper-acute rejection was observed. The 1-, 3- and 5-year patient/graft survival rates were 98.6%/96.7%, 93.1%/87.3% and 88.1%/83.6% respectively. In group 2, CsA dose ranged from 8 to 12 mg*kg(-1)*d(-1) and the graft function recovery time was 4 to 30 d, averaging 13 d. Hyper-acute rejection occurred in 9 (2.1%) and acute rejection in 198 (46.8%) cases, and the 1-, 3- and 5-year patient/graft survival rates were 86.7%/76.3%, 72.5%/67.9% and 69.5%/59.3% respectively.Negative PRA and good HLA matching can eliminate the incidences of hyper-acute rejection, decrease the rate of acute rejection and improve both patient and graft survival rates.

To evaluate the management of acute rejection (AR) after kidney transplantation and investigate the factors influencing the clinical outcome of the patients.A retrospective study was conducted in 86 cases of AR developed after primary kidney transplantation in the light of therapeutic measures, clinical outcome and prognosis.Among these patients, 81 survived AR after treatment. In patients with pulse treatment with methylprednisolone (MP), 48 out of 68 managed to survive the crises, while in those who received ATG as the first line drug therapy 10 out of 11 patients survived and in other cases, 6 out of 7 did due to first-line OKT3 administration. All the 20 patients who did not respond to MP received ATG or OKT3 instead, with 14 recovered. Of the 8 patients who failed to be cured by the management above, 6 with previous CSA treatment took FK506 and 3 were consequently cured. Five patients lost the allografts because of uncontrollable infection, allograft rupture or thrombosis.MP therapy is still the most commonly used primary treatment for acute rejection episodes. Increase of SCr by more than 10% on days 2 and 3 of MP therapy indicates poor prognosis. ATG or OKT3 can be effective against acute rejection not only as first-line but also as second-line drug. In condition of steroid-resistant rejection when ATG and OKT3 fail to manage, a change to baseline immunosuppression may be considered as the replacement of CSA with FK506.