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renal graft rejection

Renal transplant rejection: Pathology: 1) hyperacute rejection a) ABO incompatibility b) hours to days 2) acute cellular rejection a) T-cell mediated b) days to weeks c) tubulitis & endotheliitis 3) humoral rejection a) acute 1] donor-specific Ab mediated 2] PMN in peritubular capillaries 3] vasculitis 4] fibrinoid necrosis b) chronic 1] arterial intimal thickening, duplication of GBM 2] light microscopy not diagnostic 4) mechanism a) endothelial HLA class 1 & HLA class 2 expression b) donor-specific Ab Laboratory: 1) 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 2) ELISA on purified pooled HLA class 1 & HLA class 2, IgG only 3 Flow cytometry a) lymphoblastoid cells as target cells b) confirmatory testing Post-transplant assessment 1) early graft dysfunction - biopsy 2) no good marker for humoral rejection 3) C4d staining: a) in situ evidence of anti-donor humoral response b) correlation with anti-donor Ab c) peritubular endothelial cells evaluated on biopsy d) C4d staining is indicator of poor prognosis Management: 1) plasmapheresis plus anti B-cell & T-cell antibodies 2) tacrolimus 3) trimethoprim/sulfamethoxazole prophylaxis for Pneumocystis jirovecii with increased immunosuppression [2]

General

organ transplantation rejection kidney disease; renal disease

References

  1. UCLA Clinical pathology, weekly seminars, 02/11/02
  2. Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015