Rejection and Pathology
This term refers to a kidney transplant candidate who has developed multiple anti-HLA antibodies, often from prior transplants, blood transfusions, or pregnancies, making it difficult to find a compatible donor.
What is highly sensitized?
What is the common and main neurotoxic side effect of tacrolimus
What is tremor?
A 40-year-old kidney transplant recipient presents 18 months post-transplant with headaches, low-grade fever, and mild confusion. Brain MRI shows multiple ring-enhancing lesions. CD4 count is 120 cells/uL.
What is the most likely diagnosis?
What is toxoplasmosis?
74-year-old woman, 18 months post-living donor kidney transplant, presents with worsening graft function and hypertension. Doppler ultrasound reveals:
Peak systolic velocity (PSV) of 230 cm/sec in the transplant renal artery
Acceleration time (AT) of 0.15 seconds
Velocity ratio (transplant renal artery to external iliac artery) of 2.0
Tardus-parvus waveform in intrarenal arteries
Based on these findings, what is the most likely diagnosis?
What is hemodynamically significant transplant renal artery stenosis (TRAS)?
A 45-year-old man with ESRD is waitlisted for kidney transplant. He is not highly sensitized (cPRA 0%). He receives an offer for a deceased donor kidney with a KDPI of 85%.
The transplant team discusses risks and benefits.
What does a higher KDPI score, like 85%, indicate about the donor kidney?
What is higher KDPI indicates a kidney with lower expected graft longevity, often due to donor factors like older age, comorbidities, or suboptimal kidney function?
Clinical Application: A kidney with a higher KDPI might still be suitable for certain recipients, such as older patients or those with limited life expectancy.
A kidney transplant biopsy shows glomerulitis (g3), peritubular capillaritis (ptc3), C4d positivity, and circulating donor-specific antibodies (DSA).
According to Banff 2019, what is the type of rejection?
What is acute active antibody-mediated rejection (ABMR)?
Which immunosuppressant can cause hyperlipidemia and delayed wound healing?
What are mTOR inhibitors?
A 50-year-old man, 6 months after kidney transplant, presents with new-onset hematuria, and rising creatinine. Biopsy shows viral cytopathic changes in tubular epithelial cells (nuclear inclusions).
What is the most likely diagnosis?
What is BK virus nephropathy?
A 58-year-old woman, 6 weeks post-living donor kidney transplant, presents with new-onset right leg swelling and abdominal discomfort. Ultrasound shows a large, compressive fluid collection near the transplant kidney causing iliac vein compression. The fluid creatinine is similar to serum.
What is the most likely diagnosis?
What is lymphocele?
A 32-year-old woman with ESRD due to lupus nephritis is evaluated for transplant. She has no diabetes, no prior transplants, and minimal comorbidities.
Her EPTS score is calculated to be 10%.
In kidney allocation, what does a low EPTS score like 10% signify?
What is the candidate is expected to have a long post-transplant survival, making her a good match for kidneys with low KDPI?
On transplant biopsy, you see arteriolar hyalinosis, striped interstitial fibrosis, and tubular atrophy (IFTA). There is no inflammation or DSA.
What is the most likely etiology?
What is chronic calcineurin inhibitor toxicity (CNI nephrotoxicity)?
Which immunosuppressant is the common culprit for PTDM?
What is Tacrolimus?
A 5-month post-transplant patient presents with fever, malaise, leukopenia, and elevated LFTs. Likely viral culprit?
What is CMV?
This term refers to the cumulative burden of immune suppression in a transplant recipient, accounting not only for prescribed immunosuppressive medications but also for factors such as prior infections, viral co-infections (like CMV), underlying comorbidities, malnutrition, and surgical complications, all of which influence the risk of opportunistic infections and rejection.
What is the net state of immunosuppression?
A 42-year-old woman with ESRD secondary to lupus nephritis is evaluated for kidney transplant. Her medical history includes a prior kidney transplant 10 years ago, multiple blood transfusions for anemia, and two full-term pregnancies.
Under the Kidney Allocation System (KAS), which group of patients like her receives the highest priority for deceased donor kidney allocation?
What is highly sensitized patients with a cPRA close to 100%?
A kidney transplant recipient develops acute active antibody-mediated rejection (DSA+, g2, ptc3, C4d+).
According to KDIGO and current expert consensus, what is the first-line treatment approach?
What is plasmapheresis + IVIG ± rituximab ± steroids?
A 58-year-old kidney transplant recipient is on tacrolimus, mycophenolate, and prednisone. She develops a fungal nail infection and is started on fluconazole. Two weeks later, she has tremors, headaches, and elevated creatinine. Tacrolimus level is 17 ng/mL.
What is the most likely mechanism leading to elevated tacrolimus level and nephrotoxicity in this patient?
Fluconazole is a moderate CYP3A4 inhibitor, which decreases tacrolimus metabolism by hepatic CYP3A4/5 isoenzymes. This results in elevated tacrolimus levels, neurotoxicity (tremors, headache), hypertension, and nephrotoxicity (elevated creatinine).
What is the first-line management for BK viremia.
What is reduction of immunosuppression?
A 52-year-old man, 3 months post-deceased donor kidney transplant, presents with rising creatinine, anemia, thrombocytopenia, elevated LDH, and undetectable haptoglobin. Peripheral smear shows schistocytes.
Tacrolimus level is 5.5 ng/mL. Donor-specific antibodies are positive. C4d staining on biopsy is positive, showing microvascular injury and fibrin thrombi.
What is the most likely underlying etiology of his thrombotic microangiopathy?
What is antibody-mediated rejection (ABMR)-associated TMA?
In deceased donor kidney allocation, balancing fairness and maximizing outcomes can create tension between the ethical principles of equity and utility.
Which specific policy element in KAS was designed to promote equity for disadvantaged patients?
What is crediting wait time back to dialysis start date (backdating wait time), especially benefiting minorities and those with delayed referral for transplant listing?
A patient with refractory acute ABMR has already received plasmapheresis, IVIG, rituximab, and steroids. Which novel agent directly targets plasma cells and may be used in highly refractory cases?
What is bortezomib (proteasome inhibitor)?
A 45-year-old woman is 6 months post-kidney transplant. She is maintained on tacrolimus, mycophenolate mofetil, and prednisone.
She presents to clinic with leukopenia (WBC 2.5 ×10⁹/L, ANC 1,000), but her renal function remains stable. Viral PCR panels are negative. You suspect the leukopenia is medication-related.
👉Which enzyme does mycophenolate mofetil inhibit, leading to impaired lymphocyte proliferation and potentially causing leukopenia?
What is Inosine monophosphate dehydrogenase (IMPDH)?
IMPDH inhibition blocks de novo guanosine nucleotide synthesis.
T and B lymphocytes rely heavily on this pathway → selective antiproliferative effect.
A kidney transplant recipient develops hematuria, dysuria, and rising creatinine at 4 months post-transplant. Biopsy shows viral cytopathic changes. Plasma BK PCR is negative. What should you suspect?
What is adenovirus nephritis?
A 49-year-old man, 9 months after deceased donor kidney transplant, presents with fevers, hepatosplenomegaly, pancytopenia, elevated ferritin (>10,000 ng/mL), hypertriglyceridemia, and rising liver enzymes. Bone marrow biopsy shows hemophagocytosis.
EBV PCR is elevated.
What is the most likely diagnosis?
What is post-transplant hemophagocytic lymphohistiocytosis (HLH)?
A 38-year-old woman with ESRD due to Alport’s syndrome is being evaluated for kidney transplant. She has severe intellectual disability with a cognitive age equivalent of 3 years, resides in a group home, and requires 24/7 caregiver support. She has no history of nonadherence and caregivers reliably administer medications.
From an ethical and policy standpoint under U.S. transplant guidelines, which ethical principle supports her consideration for transplant listing?
What is the principle of justice (fair access to transplantation regardless of disability, provided that appropriate support exists to ensure adherence)?