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Acute TCMR Treatment — RACP Adult Medicine MCQ

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ModerateNephrologyAcute TCMR TreatmentRACP Adult Medicine

A 55-year-old renal transplant recipient (6 months post-transplant, on tacrolimus/MMF/prednisolone) develops rising creatinine from 110 to 200 μmol/L over 1 week. He has no fever. USS shows normal graft with good blood flow. Tacrolimus trough is 8 μg/L (therapeutic). BK viral load is negative. CMV PCR is negative. DSA (donor-specific antibody) screen is negative. Transplant biopsy shows tubulitis with lymphocytic interstitial infiltration (Banff 1A T-cell mediated rejection). What is the most appropriate treatment?

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Correct answer: A — IV methylprednisolone 500 mg daily for 3 days

Acute T-cell mediated rejection (TCMR) Banff 1A (mild tubulitis) is first treated with IV methylprednisolone pulse therapy (500 mg-1 g daily for 3 days). Response rate is ~80% for Banff 1A TCMR. If steroid-resistant (creatinine not improving after pulse steroids), escalate to ATG (anti-thymocyte globulin). Optimise baseline immunosuppression (check adherence, drug levels). DSA-negative status and BK/CMV negativity support the rejection diagnosis.

Reference: KDIGO – 2024 – Kidney Transplant; Banff 2022 Classification