Different types of acute rejection

What are the two different types of acute rejection?

For diagnosis, both require a kidney transplant biopsy. A patient can have a mixed rejection with features of both cell-mediated acute cellular rejection and AMR.

Acute Rejection Types

CELL-MEDIATED REJECTIONANTIBODY-MEDIATED REJECTION
Cell-mediated
Adaptive immune system
B-cell mediated
Innate immune system
Can be activated by a T-cell response
Can occur within the first few weeks of transplantCan occur within hours to days after transplant
Scr might be stable and can have subclinical rejection, though usually is elevatedWhen acute, more likely to cause rapid kidney allograft dysfunction
Proteinuria
Lymphocyte infiltration, tubulits, arteritis
Negative DSA
Negative C4d in peritubular capillaries
Intimal arteritis, peritubular capillaritis and glomerulitis, microthrombi
Positive DSA
Positive C4d in peritubular capillaries (can be negative in AMR; however, have positive DSA and other histological changes consistent with acute AMR
Treatment involves shutting down T-cell response using steroids and lymphocyte-depleting agents
Optimize maintenance immunosuppression
Treatment involves removing and shutting down antibody production using steroids, plasmapheresis, intravenous immunoglobulin, lymphocyte-depleting agents, and B-cell (rituxan, boertezomab) or compliment- specific therapies (eculizimab)
Optimize maintenance immunosuppression

AMR , Antibody-mediated rejection; DSA , donor specific antibodies; Scr , serum creatinine.

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