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Investigational methods in the diagnosis of acute renal allograft rejection

W James Chon, MD, FACP, FASN, FAST
Daniel C Brennan, MD, FACP
Section Editor
Barbara Murphy, MB, BAO, BCh, FRCPI
Deputy Editor
Alice M Sheridan, MD


The introduction of potent immunosuppressive drugs in the past three decades has led to a dramatic reduction in the incidence of acute rejection in kidney transplant recipients. At the present time, renal allograft biopsy with conventional histologic evaluation remains the gold standard for diagnosing acute rejection among patients with a deterioration in kidney function, as detected by measuring serum creatinine levels. However, the lack of additional markers of rejection makes it difficult to optimize anti-rejection therapy for transplant recipients.

The evaluation of methods other than conventional renal biopsy and/or measurement of the serum creatinine to help diagnosis acute kidney rejection has been the focus of a large number of investigators. This topic review will discuss some of the methods undergoing investigation for the diagnosis of acute rejection. The clinical diagnosis of rejection is discussed separately. (See "Clinical features and diagnosis of acute renal allograft rejection".)


Measuring the levels of urinary or circulating proteins and cytokines, circulating soluble interleukin-2 (IL-2) receptor, the urinary concentration of soluble adhesion molecules, or cellular activation with urinary flow cytometry may be helpful in diagnosing acute allograft rejection [1-9]. As examples:

A study of 367 unique human peripheral blood samples and their matched renal allograft biopsy specimens (including 115 from patients with acute rejection, 180 stable patients, and 72 with other causes of graft injury) showed that quantitative polymerase chain reaction (PCR) analysis of a five-gene set (genes involved in T/B-cell activation and leukocyte trafficking: DUSP1, PBEF1, PSEN1, MAPK9, and NKTR) was able to discriminate acute rejection from all other non-acute rejection phenotypes with 91 percent sensitivity and 90 percent specificity [10].

Urinary expression of a three-gene signature that included CD3ε mRNA, interferon-inducible protein 10 (IP-10) and 18S rRNA discriminated acute rejection from no rejection among transplant recipients in a multicenter study [11]. Forty three urine samples were compared with matched biopsies (38 indication and 5 surveillance from 34 patients) that showed acute rejection. One-hundred sixty-three urine samples were compared with 163 biopsies (107 indication and 56 surveillance) that did not show rejection and with 1501 urinary samples from 201 patients who did not undergo biopsy.

Urinary concentrations of mRNA for CD3ε, perforin, granzyme B, IP-10, and 18s RNA were higher in patients with acute rejection compared with those without rejection. Receiving operator characteristic (ROC) analysis of a selected parsimonious three-gene model including CD3ε mRNA, IP-10, and 18S rRNA demonstrated an area under the curve (AUC) of 0.85 (95% CI 0.78-0.91), which had a sensitivity and specificity of 79 and 78 percent, respectively.

In an external validation set derived from 24 separate biopsy samples that showed acute rejection and 47 biopsy samples randomly selected from transplant recipients enrolled in a separate clinical trial, ROC analysis yielded an AUC of 0.74 (95% CI 0.61-0.86), which was not different from the AUC used to construct the original model. In the validation set, the three-gene signature had a sensitivity and specificity of 71 and 72 percent, respectively.

This molecular signature could also distinguish between acute cellular and antibody-mediated rejection and could identify patients who had received IL-2 receptor antibodies versus those who had received T-cell depleting antibodies for induction.

The three-gene signature profile, however, was also elevated in urine samples from patients with BK virus infection [12].

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Literature review current through: Nov 2017. | This topic last updated: Mar 04, 2014.
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  1. Simpson MA, Madras PN, Cornaby AJ, et al. Sequential determinations of urinary cytology and plasma and urinary lymphokines in the management of renal allograft recipients. Transplantation 1989; 47:218.
  2. Yoshimura N, Oka T, Kahan BD. Sequential determinations of serum interleukin 6 levels as an immunodiagnostic tool to differentiate rejection from nephrotoxicity in renal allograft recipients. Transplantation 1991; 51:172.
  3. Forsythe JL, Shenton BK, Parrot NR, et al. Plasma interleukin 2 receptor levels in renal allograft dysfunction. Transplantation 1989; 48:155.
  4. Bechtel U, Scheuer R, Landgraf R, et al. Assessment of soluble adhesion molecules (sICAM-1, sVCAM-1, sELAM-1) and complement cleavage products (sC4d, sC5b-9) in urine. Clinical monitoring of renal allograft recipients. Transplantation 1994; 58:905.
  5. Casiraghi F, Ruggenenti P, Noris M, et al. Sequential monitoring of urine-soluble interleukin 2 receptor and interleukin 6 predicts acute rejection of human renal allografts before clinical or laboratory signs of renal dysfunction. Transplantation 1997; 63:1508.
  6. Roberti I, Panico M, Reisman L. Urine flow cytometry as a tool to differentiate acute allograft rejection from other causes of acute renal graft dysfunction. Transplantation 1997; 64:731.
  7. Li B, Hartono C, Ding R, et al. Noninvasive diagnosis of renal-allograft rejection by measurement of messenger RNA for perforin and granzyme B in urine. N Engl J Med 2001; 344:947.
  8. Vasconcellos LM, Schachter AD, Zheng XX, et al. Cytotoxic lymphocyte gene expression in peripheral blood leukocytes correlates with rejecting renal allografts. Transplantation 1998; 66:562.
  9. De Serres SA, Mfarrej BG, Grafals M, et al. Derivation and validation of a cytokine-based assay to screen for acute rejection in renal transplant recipients. Clin J Am Soc Nephrol 2012; 7:1018.
  10. Li L, Khatri P, Sigdel TK, et al. A peripheral blood diagnostic test for acute rejection in renal transplantation. Am J Transplant 2012; 12:2710.
  11. Suthanthiran M, Schwartz JE, Ding R, et al. Urinary-cell mRNA profile and acute cellular rejection in kidney allografts. N Engl J Med 2013; 369:20.
  12. Dharnidharka VR, Storch GA, Brennan DC. Urinary-cell mRNA and acute kidney-transplant rejection. N Engl J Med 2013; 369:1858.
  13. Muthukumar T, Dadhania D, Ding R, et al. Messenger RNA for FOXP3 in the urine of renal-allograft recipients. N Engl J Med 2005; 353:2342.
  14. Renesto PG, Ponciano VC, Cenedeze MA, et al. High expression of Tim-3 mRNA in urinary cells from kidney transplant recipients with acute rejection. Am J Transplant 2007; 7:1661.
  15. Manfro RC, Aquino-Dias EC, Joelsons G, et al. Noninvasive Tim-3 messenger RNA evaluation in renal transplant recipients with graft dysfunction. Transplantation 2008; 86:1869.
  16. Suthanthiran M. Acute rejection of renal allografts: mechanistic insights and therapeutic options. Kidney Int 1997; 51:1289.
  17. Strehlau J, Pavlakis M, Lipman M, et al. Quantitative detection of immune activation transcripts as a diagnostic tool in kidney transplantation. Proc Natl Acad Sci U S A 1997; 94:695.
  18. Sarwal M, Chua MS, Kambham N, et al. Molecular heterogeneity in acute renal allograft rejection identified by DNA microarray profiling. N Engl J Med 2003; 349:125.
  19. Schaub S, Rush D, Wilkins J, et al. Proteomic-based detection of urine proteins associated with acute renal allograft rejection. J Am Soc Nephrol 2004; 15:219.
  20. Desvaux D, Schwarzinger M, Pastural M, et al. Molecular diagnosis of renal-allograft rejection: correlation with histopathologic evaluation and antirejection-therapy resistance. Transplantation 2004; 78:647.
  21. Hoffmann SC, Hale DA, Kleiner DE, et al. Functionally significant renal allograft rejection is defined by transcriptional criteria. Am J Transplant 2005; 5:573.
  22. Strom TB, Suthanthiran M. Transcriptional profiling to assess the clinical status of kidney transplants. Nat Clin Pract Nephrol 2006; 2:116.
  23. Bestard O, Cruzado JM, Rama I, et al. Presence of FoxP3+ regulatory T Cells predicts outcome of subclinical rejection of renal allografts. J Am Soc Nephrol 2008; 19:2020.
  24. Mansour H, Homs S, Desvaux D, et al. Intragraft levels of Foxp3 mRNA predict progression in renal transplants with borderline change. J Am Soc Nephrol 2008; 19:2277.
  25. Flechner SM, Kurian SM, Head SR, et al. Kidney transplant rejection and tissue injury by gene profiling of biopsies and peripheral blood lymphocytes. Am J Transplant 2004; 4:1475.