rejection is one of renal tx complications, the earlier the rejection the poorer the prognosis

1. Workshop 1: Rejection
By
Salwa Mahmoud Elwasif, MD
Fellow of Internal Medicine & Nephrology
Urology and Nephrology Center
Mansoura University

2. A 23-year-old male patient.
 ESRD on CHD since Dec. 2015
 Original kidney disease: VUR.
Family history: Father has ESKD,
history of Consanguinity

3. Medical history:
 Hypertension .
 Anemia: History of blood transfusion, twice
Surgical history:
 Left B/C AVF, Dec., 2015
 Left Nephroureterectomy : Feb. 2019

4. Donor: unrelated lady.
Donor`s age: A 34-year old.
Blood group: O+ve to B+ve.
Immunological data:
• HLA: 25 % , DR: 50 %,
• PRA class I: 36% , class II: 14%.NS ( 2018)
Zero% (7/2019) & (8/2019)

5. Left open nephrectomy
GFR: 54.6 ml/minute (44.8%).
 Remaining kidney:
GFR: 67.1 ml/min (55.2%).

6.  Right iliac renal allotransplantation.
 Anastomosis of the graft artery to the internal iliac
artery.
 Anastomosis of the graft vein to the external iliac vein.
 Uretervesical anastomosis : No ureteric stented.
The transplant surgery

7.  Ischemia time: 38 minutes
 Immediate diuresis.
The transplant surgery

8. Induction: ATG.
 Maintenance:
 (steroid-Tac-MMF)
Immunosuppression

9. Post operative course
FK level= 5.3ng/ml
pyuria
Urine
culture

10. Case No.1
 Pelvi abdominal US:
 Minimal perigraft collection and pelvic free fluid .
 Doppler:
 good cortical perfusion, RI 0.54
Post operative course

11. • Radiology:

12. Non obstructive graft

13. • Empirical antibiotic
– Hypersensitivity to ceftriaxone.
• +ve Fluid balance
Management

14. Post operative course

15. •What is the next step?
• A 23 year-old gentleman
• Kidney transplant ( day 17)
• Graft impairment
• Urinalysis showed pyuria, urine culture no growth.
• Afebrile, no leukocytosis
• Accepted FK level

16. • Graft biopsy

17. Glomerulitis g2

18. Peritubular capillaritis
(ptc2)
Tubulitis (t3)

19. negative

20. • I.V. Methylprednisolone 500mg /day for 5days
Management

21. • Repeated PRA:
• class I: 0 %
• class II: 17%.NS

22. Management
Day 21:
• Plasma exchange EOD
• IvIg

23. 0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
DAY17 DAY18 DAY19 DAY20 DAY21 DAY22 DAY23 DAY24 DAY25 DAY26 DAY27
S.Creatinine
S.Creatinine

24. OPC, 25th Sept. 2019
•S. Cr. 1.4 mg/dl
•FK level: 11.4ng/ml
• Pyuria: 10: 15 /HPF
Condition at last follow up

25. • A 23 year-old gentleman.
• ESKD, Renal transplant recipient
• OKD: VUR
• Day 10: sterile pyuria
• Day 17: biopsy proven rejection
• Received pulse steroid, plasma pharesis and IvIg.
Summary

26. Review of Literatures
• Causes of Sterile Pyuria:
DIETER, 2000

29. • The clinical, histological, and immunological
assessment of response to treatment of acute TCMR
revealed different profiles of the response to treatment
with distinct outcomes.

30. • the main determinants of the prognostic heterogeneity in patients with
acute TCMR and drove two distinct patterns of nonresponse
represented by the transition towards chronic active TCMR and active
AMR, respectively. The present results highlight an urgent need to
reconsider the natural history and impact of acute TCMR in kidney
transplantation and pave new avenues for the development of
improved monitoring of patients with acute TCMR and second‐line
therapeutic strategies in nonresponders to treatment.

31. Mansoura Experience

35. To be continued:
? infection
Rejection
Follow up