renal graft rejection
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Introduction
Renal transplant rejection:
Pathology
- hyperacute rejection
- ABO incompatibility
- hours to days
- acute cellular rejection
- T-cell mediated
- days to weeks
- tubulitis & endotheliitis
- humoral rejection
- acute
- donor-specific Ab mediated
- PMN in peritubular capillaries
- vasculitis
- fibrinoid necrosis
- chronic
- arterial intimal thickening, duplication of GBM
- light microscopy not diagnostic
- acute
- mechanism
- endothelial HLA class 1 & HLA class 2 expression
- donor-specific Ab
Laboratory
- Panel-reactive antibody assay
- complement-dependent cytotoxicity (IgM or IgG)
- cell lysis allows entry of dye
- 40-120 wells for T-cells, HLA class 1
- 25 wells for B-cells, HLA class 1 & HLA class 2
- complement-dependent cytotoxicity (IgM or IgG)
- ELISA on purified pooled HLA class 1 & HLA class 2, IgG only 3 Flow cytometry
- lymphoblastoid cells as target cells
- confirmatory testing
Post-transplant assessment
- early graft dysfunction - biopsy
- no good marker for humoral rejection
- C4d staining:
- in situ evidence of anti-donor humoral response
- correlation with anti-donor Ab
- peritubular endothelial cells evaluated on biopsy
- C4d staining is indicator of poor prognosis
Management
- plasmapheresis plus anti B-cell & T-cell antibodies
- tacrolimus
- trimethoprim/sulfamethoxazole prophylaxis for Pneumocystis jirovecii with increased immunosuppression[2]