Treatment of acute T cell-mediated (cellular) rejection of the renal allograft
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Medical Director and Co-Director of the Comprehensive Transplant Center, Department of Internal Medicine, Division of Nephrology
- Johns Hopkins Medical School
- Andrew Malone, MB, BCh, MRCPI
Andrew Malone, MB, BCh, MRCPI
- Assistant Professor of Medicine, Division of Nephrology
- Department of Medicine, Washington University School of Medicine
The use of potent immunosuppressive agents as part of induction and maintenance therapy for renal transplantation has significantly reduced the incidence of acute rejection, which is defined as an acute deterioration in kidney allograft function associated with specific pathologic changes in the graft. With existing immunosuppressive protocols, acute rejection rates have fallen to approximately 8 percent at most transplant centers .
Acute rejection can be broadly categorized into T cell-mediated (cellular) rejection (TCMR) and antibody-mediated (previously known as humoral) rejection (ABMR). A renal allograft biopsy is required to establish the diagnosis and determine the severity of rejection in order to determine the appropriate approach to therapy. TCMR and ABMR may also coexist at the same time in the renal allograft (ie, mixed acute rejection). The presence of histologic evidence of acute rejection on biopsy without an elevation in the serum creatinine concentration is known as subclinical rejection.
The treatment of acute TCMR of the renal allograft will be reviewed here. The clinical features and diagnosis of acute rejection and the treatment of acute ABMR are discussed separately. (See "Clinical features and diagnosis of acute renal allograft rejection" and "Prevention and treatment of antibody-mediated rejection of the renal allograft".)
OUTCOMES AND PROGNOSIS
Acute TCMR occurs most commonly within the first year after transplantation and rarely occurs after five years posttransplant [2,3]. In general, episodes of acute rejection have been associated with a reduction in long-term allograft survival, although not all rejection episodes have the same impact on long-term graft function. (See "Clinical features and diagnosis of acute renal allograft rejection", section on 'Epidemiology and outcomes' and "Risk factors for graft failure in kidney transplantation", section on 'Episodes of acute rejection'.)
The impact of successfully treating acute TCMR on graft outcomes has not been well studied. Greater histologic severity of acute TCMR (ie, Banff grade greater than IA) has been associated with lower response rates to therapy . Higher histologic scores (eg, i: interstitial inflammation, t: tubulitis, v: intimal arteritis) and a later onset of rejection (>3 months posttransplant) have been associated with worse graft outcomes [5,6]. (See "Clinical features and diagnosis of acute renal allograft rejection", section on 'Acute T cell-mediated (cellular) rejection'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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