A 35-year-old kidney transplant recipient on tacrolimus, mycophenolate, and prednisolone presents 5 months post-transplant with rising creatinine (180 to 310 μmol/L over 4 weeks). Kidney biopsy shows interstitial fibrosis and tubular atrophy with intimal arteritis. This is classified as:
- A T-cell mediated rejection (TCMR) — treat with IV methylprednisolone pulse ✓
- B Antibody-mediated rejection (ABMR) — treat with IVIg and plasmapheresis
- C Tacrolimus nephrotoxicity — reduce tacrolimus dose
- D BK virus nephropathy — reduce immunosuppression
Explanation
Banff 2019 classification of renal allograft rejection: Intimal arteritis (endarteritis, v-lesion) on biopsy in the context of rising creatinine is diagnostic of T-cell mediated rejection (TCMR), classified as Banff Grade IIA/IIB/III depending on severity of arteritis. Treatment: high-dose IV methylprednisolone (500 mg daily × 3 days) reverses most TCMR episodes. ABMR is characterized by peritubular capillaritis, glomerulitis, and C4d deposits with donor-specific antibodies (DSA). BK nephropathy shows characteristic nuclear inclusions (decoy cells) and requires reduction rather than augmentation of immunosuppression. Tacrolimus nephrotoxicity causes arteriolar hyalinosis and striped fibrosis, not intimal arteritis.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.