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Acute Transplant Rejection — RACP Adult Medicine MCQ

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ModerateNephrologyAcute Transplant RejectionRACP Adult Medicine

A 55-year-old man with ESKD receives a deceased donor kidney transplant. On postoperative day 7, his creatinine rises from 120 to 250 µmol/L. Ultrasound shows no obstruction and good vascular flow. His tacrolimus trough level is 8 µg/L (therapeutic). What is the most important investigation?

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Correct answer: E — Renal transplant biopsy

Acute rise in creatinine post-transplant with patent vessels and no obstruction requires urgent transplant biopsy to distinguish between acute rejection (cellular or antibody-mediated), acute tubular necrosis, drug toxicity, and infection (BK nephropathy). Banff classification guides treatment. Histology is the gold standard and should not be delayed by additional non-invasive testing. Early detection of rejection improves graft survival.

Reference: KHA-CARI – 2013 – Transplant Guidelines; KDIGO – 2024 – Kidney Transplant Care