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Transplant Rejection — ESENeph MCQ

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HardTransplantationTransplant RejectionESENeph

A kidney transplant recipient 8 months post-transplant develops rising creatinine from 120 to 185 umol/L over 2 weeks. Tacrolimus trough is 5.8 ng/mL. He has donor-specific antibodies (DSA) detected. Biopsy shows microvascular inflammation, C4d positivity in peritubular capillaries, and transplant glomerulopathy. What is the most likely diagnosis?

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Correct answer: E — Antibody-mediated rejection (AMR)

The combination of rising creatinine, new DSA, microvascular inflammation, C4d-positive peritubular capillary staining, and transplant glomerulopathy on biopsy meets Banff 2019 criteria for antibody-mediated rejection (AMR). T-cell mediated rejection typically shows tubulitis and interstitial inflammation without C4d. BK nephropathy shows viral cytopathic changes. CNI toxicity shows arteriolar hyalinosis without C4d.

Reference: Banff 2019 – Classification of Renal Allograft Pathology; KDIGO 2009 – Transplant Guideline