Serum amyloid A protein is a clinically useful indicator of acute renal allograft rejection

Early diagnosis of acute rejection after renal transplantation is important. There is evidence that measurement of the acute phase proteins, C-reactive protein (CRP) and serum amyloid A protein (SAA) is helpful. In 64 consecutive patients, CRP was measured in a routine clinical system (Technicon RA1000, Bayer) and SAA in a new sensitive automated immunoassay on the Abbott IMx instrument, daily or on alternate days for 30 days after renal transplantation. Patients all received triple immunosuppression with cyclosporin, azathioprine, and prednisolone and all mounted a post-surgical acute phase response of SAA, but the CRP response was reduced or absent. Serum creatinine rose significantly in 36 patients, leading to treatment for first rejection. Thirty of these episodes were confirmed rejection, three were definitely not and three were uncertain. SAA. normally < 10 mg/l, rose to more than 100 mg/l in all episodes except when rejection was definitely absent. In six cases SAA rose above 100 mg/l 1-3 days before the rise in creatinine leading to antirejection therapy, and only twice did creatinine rise 1 day before SAA. In contrast, CRP responses to rejection were modest or absent. In four patients there were SAA and CRP responses unrelated to rejection, three associated with intercurrent infection and one with administration of antilymphocyte globulin. There were also two unexplained isolated spikes of SAA. SAA is a sensitive marker of acute renal allograft rejection. It is not specific, but the differential behaviour of CRP in patients receiving cyclosporin helps to distinguish infection from rejection. Availability of rapid assays for these analytes should facilitate management of renal allograft recipients.