Rechazo agudo del trasplante renal: diagnóstico y alternativas terapéuticas

Abstract

The main aim of renal transplantation is to achieve the longest patient and graft survival, in part by optimising immunological tolerance of the graft. Acute rejection decreases graft survival in the long term. The aim of this review is to describe the diagnosis criteria for acute rejection, the new classification tools, and its therapeutic alternatives.

The diagnosis of acute kidney injury (AKI) in renal transplantation is a challenge, given the variability of serum creatinine results related to the titration of immunosuppressive drugs and the volume status. Serum creatinine as a biomarker of acute rejection has a low sensitivity and specificity.

The diagnosis of rejection is made using the Banff criteria. The criteria for T-cell mediated rejection have not changed significantly in the past 10 years. However, the category of antibody-mediated rejection was modified in 2013 by adding rejection mediated by C4d-negative antibodies. For the diagnosis of antibody-mediated rejection, 3 main factors are required concomitantly: histological lesions, evidence of antibody-endothelium interaction, and specific donor antibodies.

The quality of the evidence for the different options available for rejection treatment is low. The treatment of cellular rejection has not changed in the last decades and is based on corticosteroids and / or thymoglobulin. Treatment of antibody-mediated rejection is based on the removal of antibodies by immunoadsorption or plasmapheresis, with great variability between transplant centres in terms of complementary treatments (steroids, polyvalent human gammaglobulin, bortezomib, rituximab and/or eculizumab) in order to prevent their production.