General principles when treating acute cell mediated rejection

What are some general principles when treating acute cell mediated rejection?

  • • Pulse dose corticosteroids, typically methylprednisolone 500 mg daily intravenously for 3 days are considered the first-line therapy for Banff class IA. In higher grades of rejection beyond Banff IA pulse corticosteroids are routinely used as well but in concert with other more potent drugs such as lymphocyte depleting agents.
  • • Optimizing maintenance immunosuppression. The calcineurin inhibitor dose should be adjusted if levels preceding the acute rejection episode were sub-therapeutic. If tolerable, the dose of mycophenolate mofetil/mycophenolic acid should be increased. Typically, a steroid taper is given as well.
  • • Lymphocyte-depleting agents are used regularly for Grade 1B rejection or a higher grade of rejection. They are used in Grade1A if the rejection is resistant to steroids. Thymoglobulin is the common lymphocyte-depleting agent used.

If there is no response, the possibility of AMR should be considered. Patients should be assessed for DSA and the biopsy stained for C4d staining. A repeat kidney transplant biopsy should also be considered. If there are no contraindications, an alternate lymphocyte-depleting agent (CampathH-1), plasmapheresis, and/or intravenous immune globulin may be considered. The decision to discontinue therapy should be based on many factors, but mainly the recipient’s clinical status and degree of damage on repeat allograft biopsy.

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