Different types of acute rejection

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

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
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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