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Borderline Rejection Biopsy Management — ESENeph MCQ

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ModerateTransplantationBorderline Rejection Biopsy ManagementESENeph

A kidney transplant recipient on Tacrolimus and Mycophenolate has rising creatinine at 3 months post-transplant. Biopsy shows borderline changes (mild tubulitis t1, minimal interstitial inflammation i0). C4d is negative. DSA are absent. Tacrolimus trough is 7 ng/mL. What is the recommended management?

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Correct answer: B — Optimise Tacrolimus level and repeat biopsy in 2-4 weeks if creatinine continues to rise – borderline changes alone do not mandate anti-rejection treatment

Banff 'borderline' changes (suspicious for TCMR but not diagnostic) are common and do not always represent rejection. KDIGO 2009 recommends individualised management: ensuring adequate immunosuppressive levels, monitoring creatinine trend, and repeating biopsy if deterioration continues. Treating borderline changes with pulse steroids carries unnecessary infection and metabolic risk. If creatinine stabilises with Tacrolimus optimisation, no further treatment may be needed. Clinical context (DSA status, compliance, infection screen) guides the decision.

Reference: Banff 2019 Classification; KDIGO 2009 – Transplant