A 35-year-old man with end-stage renal disease secondary to IgA nephropathy receives a living-related kidney transplant from his HLA-matched sibling. On postoperative day 5, he develops fever, oliguria, and graft tenderness. Renal biopsy shows diffuse interstitial lymphocytic infiltration with tubulitis (Banff Grade IA acute cellular rejection). The most appropriate first-line treatment is:
- A Plasmapheresis + IV immunoglobulin for antibody-mediated rejection
- B IV methylprednisolone 500 mg/day for 3 days (pulse steroids) ✓
- C Rituximab (anti-CD20) to deplete B cells
- D Switch tacrolimus to cyclosporine
Explanation
Banff Grade IA acute cellular rejection (ACR, also called T-cell mediated rejection — TCMR) is characterized by interstitial infiltration of ≥25% of the parenchyma and tubulitis with 1-4 mononuclear cells/tubular cross-section. First-line treatment is high-dose IV methylprednisolone (pulse steroids: 500 mg daily for 3 days), which reverses ACR in 70-80% of cases by depleting lymphocytes and inhibiting cytokine production. Plasmapheresis + IVIG is the treatment for antibody-mediated rejection (AMR), which shows C4d staining, DSA positivity, and peritubular capillaritis on biopsy — a distinct entity. Rituximab is an adjunct for refractory AMR.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.