Presentation, diagnosis and treatment of acute rejection

In the current transplant era, potent immunosuppressive agents have significantly lowered the incidence of acute cellular rejection in the first years after transplantation. Renal allograft biopsy has become the gold standard for diagnosing transplant rejection. Infiltration of lymphocytes is the hallmark, histological sign of cellular rejection. In contrast for acute humoral rejection, C4d deposition in peritubular capillaries of renal allografts has been demonstrated to be a sensitive and diagnostic marker. While pulse dose corticosteroids and polyclonal antibodies are effective treatments for cellular rejection, acute humoral rejection has a poorer prognosis and historically, has been very difficult to reverse and not well studied. Treatment regimens may include one or more of the following: anti-lymphocyte agents, plasmapheresis, intravenous immunoglobulin, rituximab, bortezomib, and eculizumab. This chapter will review the types of transplant rejection, histological presentation, and critically analyze available treatment options.