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What are the different types of acute rejection?
Most commonly, there are two types of acute rejection
For the purpose of diagnosis, both these types of acute rejection require a kidney transplant biopsy.
There is a high possibility that one can have a mixed rejection with features of both cell mediated acute cellular rejection and antibody mediated rejection (AMR).
Acute Rejection Types
CELL-MEDIATED REJECTION | ANTIBODY-MEDIATED REJECTION (AMR) |
---|---|
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 transplant | Can occur within hours to days after transplant |
Scr might be stable and can have subclinical rejection, though usually is elevated | When 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.