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T-Cell Mediated Rejection — ESENeph MCQ

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ModerateTransplantationT-Cell Mediated RejectionESENeph

A 44-year-old man undergoes a living-donor kidney transplant. His pre-transplant panel-reactive antibodies (PRA) are 0%, and he receives Basiliximab induction. On day 7 post-transplant, creatinine fails to fall as expected and rises to 180 umol/L. Ultrasound shows good perfusion. Tacrolimus trough is 9.2 ng/mL. Transplant biopsy shows tubulitis (t2) and interstitial inflammation (i2), C4d negative. What is the diagnosis and first-line treatment?

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Correct answer: A — Acute T-cell mediated rejection – IV Methylprednisolone

Biopsy findings of tubulitis (t2) and interstitial inflammation (i2) without C4d positivity are consistent with Banff criteria for acute T-cell mediated rejection (TCMR). First-line treatment is pulse IV Methylprednisolone (typically 500 mg daily for 3 days). Anti-thymocyte globulin is reserved for steroid-resistant TCMR. The Tacrolimus level is within target range, making CNI toxicity less likely.

Reference: Banff 2019 Classification; KDIGO 2009 – Transplant Guideline