Diagnosis and treatment of acute cell-mediated rejection in kidney transplantation

Authors

  • Aris Tsalouchos Azienda USL Toscana Centro, SOS Nefrologia e Dialisi, Ospedale SS. Cosma e Damiano, Pescia, Pistoia - Italia
  • Maurizio Salvadori Professore di Nefrologia già Direttore di Nefrologia e Trapianto, Azienda Ospedaliero-Universitaria Careggi, Firenze - Italia

DOI:

https://doi.org/10.33393/gcnd.2020.1099

Keywords:

ATG, Diagnosis of acute rejection, Methylprednisolone, Pathology of acute rejection, T cell in acute rejection, Treatment of acute rejection

Abstract

The incidence of acute rejection of the kidney allograft in the world has been around 15% during the period between 2001 and 2003. It is clinically defined as an elevation in the level of serum creatinine by more than 0.3 mg/dL and is diagnosed by kidney biopsy. On pathologic examination, the interstitium of the allograft is diffusely edematous and infiltrated by CD4 and CD8 lymphocytes. Tubulitis occurs when the lymphocytes and monocytes extend into the walls and lumina of the tubules. Presence of leukocytes determines infection or antibody-mediated rejection. Typically C4d staining is negative. Other causes of acute allograft dysfunction included prerenal factors, interstitial nephritis, infection, acute tubular necrosis, toxicity by drugs, and obstruction in the urinary tract. The primary diagnostic assessments include history, especially adherence to immunosuppressive therapy, physical examination, blood and urine laboratory tests, measurement of the serum levels of the drugs, and ultrasonography. Diagnosis of acute cellular rejection depends on biopsy, CD20 staining for refractory cases, negative C4d staining, presence of markers of activating lymphocyte, and proteomic study. Treatment of acute cellular rejection in kidney transplant recipients include pulse steroid for the first rejection episode. It can be repeated for recurrent or resistant rejection. Thymoglobulin and OKT3 are used as the second line of treatment if graft function is deteriorating. Changing the protocol from cyclosporine to tacrolimus or adding mycophenolate mofetil or sirolimus might be effective. Prognosis depends on number of rejection episodes, the use of potent drugs, time of rejection from transplantation, and response to treatment.

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References

Roufosse C, Simmonds N, Clahsen-van Groningen M, et al. A 2018 Reference Guide to the Banff Classification of Renal Allograft Pathology. Transplantation. 2018;102(11):1795-814.

Salvadori M, Tsalouchos A. Biomarkers in renal transplantation: An updated review. World J Transplant. 2017;7(3):161-78.

Köhnke R, Kentrup D, Schütte-Nütgen K, et al. Update on imaging-based diagnosis of acute renal allograft rejection. Am J Nucl Med Mol Imaging. 2019;9(2):110-26.

Tanriover B, Jaikaransingh V, MacConmara MP, et al. Acute Rejection Rates and Graft Outcomes According to Induction Regimen among Recipients of Kidneys from Deceased Donors Treated with Tacrolimus and Mycophenolate. Clin J Am Soc Nephrol. 2016;11(9):1650-61.

Brennan DC, Alhamad T, Malone A. Clinical features and diagnosis of acute renal allograft rejection. https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-acute-renal-allograft-rejection?source=bookmarks_widget#H792385721. Accessed August 25, 2019.

Jehn U, Schuette-Nuetgen K, Kentrup D, Hoerr V, Reuter S. Renal Allograft Rejection: Non invasive Ultrasound- and MRI-Based Diagnostics. Contrast Media Mol Imaging. 2019 Apr 10;2019:3568067.

Grabner A, Kentrup D, Mühlmeister M, et al. Noninvasive imaging of acute renal allograft rejection by ultrasound detection of microbubbles targeted to T-lymphocytes in rats. Ultraschall Med. 2016;37(1):82-91.

van Eijs MJM, van Zuilen AD, de Boer A, et al. Innovative perspective: gadolinium-free magnetic resonance imaging in long-term follow-up after kidney transplantation. Front Physiol. 2017;8:296.

Loupy A, Haas M, Solez K, et al. The Banff 2015 Kidney meeting report: current challanges in rejection classification and prospects for adopting molecular pathology. Am J Transplant. 2017;17(17):28-41.

Minervini MI, Torbenson M, Scantlebury V, et al. Acute renal allograft rejection with severe tubulitis (Banff 1997 grade IB). Am J Surg Pathol. 2000;24(4): 553-8.

Boothpur R, Hardinger KL. Skelton RM, et al. Serum sickness after treatment with rabbit antithymocyte globulin in kidney transplant recipients with previous rabbit exposure. Am J Kidney Dis. 2010;55:141-3.

Freue GV, Sasaki M, Meredith A, et al. Proteomic signatures in plasma during early acute renal allograft rejection. Mol Cell Proteomics. 2010;9(9):1954-1967.

Sigdel TK, Kaushal A, Gritsenko M, et al. Shotgun proteomics identifies proteins specific for acute renal transplant rejection. Proteomics Clin Appl. 2010;4(1):32-47.

Wu D, Zhu D, Xu M, et al. Analysis of transcriptional factors and regulation networks in patients with acute renal allograft rejection. J Proteom Res. 2011;10: 175-181.

Loftheim H, Midtvedt K, Hartmann A, et al. Urinary proteomic shotgun approach for identification of potential acute rejection biomarkers in renal transplant recipients. Transplant Res. 2012;31;1(1):9.

Sigdel TK, Salomonis N, Nicora CD, et al. The identification of novel potential injury mechanisms and candidate biomarkers in renal allograft rejection by quantitative proteomics. Mol Cell Proteomics. 2014;13(2):621-631.

Published

2020-02-27

How to Cite

Tsalouchos, A., & Salvadori, M. (2020). Diagnosis and treatment of acute cell-mediated rejection in kidney transplantation. Giornale Di Clinica Nefrologica E Dialisi, 32(1), 22–25. https://doi.org/10.33393/gcnd.2020.1099
Received 2019-12-23
Accepted 2019-12-31
Published 2020-02-27

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