A patient with end-stage renal disease receives a deceased donor kidney transplant. On day 3, the transplanted kidney shows decreased urine output, rising creatinine, and on biopsy: tubulitis (> 10 T-lymphocytes/tubular cross-section) with intimal arteritis. C4d staining is negative. According to Banff 2019 classification, what is this rejection type and its treatment?
- A Antibody-mediated rejection (AMR) — treat with plasmapheresis + IVIG + rituximab
- B Hyperacute rejection — immediate graft nephrectomy required
- C Acute T-cell mediated rejection (TCMR), Banff grade IIA — treat with high-dose IV methylprednisolone pulse (500 mg × 3 days) ✓
- D Delayed graft function (ischaemia-reperfusion injury) — conservative management with dialysis support
Explanation
Banff 2019 classification: T-cell mediated rejection (TCMR) is characterised by tubulitis (t score) ± intimal arteritis (v score). Grade IA = tubulitis ≥ 4 lymphocytes/tubular cross-section without arteritis; Grade IIA = intimal arteritis involving <25% luminal area (v1). Negative C4d excludes antibody-mediated rejection (which requires C4d positivity or donor-specific antibodies with microvascular inflammation). Hyperacute rejection occurs within minutes to hours due to preformed antibodies (positive crossmatch). Delayed graft function would show acute tubular injury on biopsy without tubulitis. TCMR IIA is treated with high-dose IV methylprednisolone 500 mg/day for 3 days; steroid-resistant cases receive anti-thymocyte globulin (ATG).
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.