A renal transplant recipient on tacrolimus, mycophenolate, and prednisolone develops acute T-cell mediated rejection at 3 weeks post-transplant. What is the first-line treatment?
- A High-dose IV methylprednisolone pulses (500 mg daily for 3 days) ✓
- B Rituximab (anti-CD20)
- C Plasmapheresis and IVIG
- D Belatacept
Correct answer: A. High-dose IV methylprednisolone pulses (500 mg daily for 3 days)
Explanation
Acute T-cell mediated (cellular) rejection is the most common type of acute rejection and is managed with high-dose pulsed IV methylprednisolone (500mg daily for 3 days) as the first-line treatment, which reverses rejection in approximately 75-80% of cases. Steroid-resistant acute cellular rejection is then treated with anti-thymocyte globulin (ATG). Antibody-mediated rejection (ABMR) — characterized by C4d deposition and donor-specific antibodies — is treated with plasmapheresis, IVIG, and rituximab. Rituximab is not first-line for T-cell mediated rejection.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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