Borderline rejection after renal transplantation – to treat or not to treat

Abstract

According to the Banff classification of renal allograft pathology, the category borderline changes defines changes insufficient for a diagnosis of acute rejection. The relationship between borderline changes and acute renal allograft rejection still remains unclear. The appropriate clinical management for patients showing such changes is controversial. One possible interpretation of the high incidence of subacute tubulitis is that these changes in the absence of graft dysfunction are of no consequence and that treatment with intensified immunosuppression is unnecessary and perhaps harmful. Another view, consistent with the high incidence of CAN in late protocol biopsy studies, is that immunosuppression has become so powerful, that rejection may not even be manifested by a rising serum creatinine. Borderline changes should be used as part of an algorithm, but not as the only criterion, for therapeutic decision making. Based on the weak evidence of existing studies, in our patients with clinical borderline rejection, we have to weigh the individual immunological risk against the potential side effects of increased immunosuppression. Even in the knowledge that a majority of patients with borderline infiltrates will not progress into rejection, in many transplant centers, borderline rejection is treated with additional steroids or augmentation of maintenance immunosuppression.

Fluorodeoxyglucose F18 Positron Emission Tomography Coupled With Computed Tomography in Suspected Acute Renal Allograft Rejection

“…The area under the receiver operating characteristic curve was 0.93, with 100% sensitivity and 50% specificity using a mean SUV threshold of 1.6. In conclusion, 18 …”

“…AR involves recruitment of leukocytes avid for fluorodeoxyglucose F 18 ( 18 F-FDG), thus 18 F-FDG positron emission tomography (PET) coupled with computed tomography (CT) may noninvasively distinguish nonrejection from AR. From January 2013 to February 2015, we prospectively performed 32 18 F-FDG PET/CT scans in 31 adult KTRs with suspected AR who underwent transplant biopsy. Biopsies were categorized into four groups: normal (n ¼ 8), borderline (n ¼ 10), AR (n ¼ 8), or other (n ¼ 6, including 3 with polyoma BK nephropathy).…”

“…Estimated GFR was comparable in all groups. PET/CT was performed 201 AE 18 minutes after administration of 3.2 AE 0.2 MBq/kg of 18 F-FDG, before any immunosuppression change. Mean standard uptake values (SUVs) of both upper and lower renal poles were measured.…”

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“…There is a need, therefore, for more objective criteria to differentiate borderline rejection from nonrejection borderline lymphocytic infiltrates. 11,12 There are limitations in this study. This was a small-scale, single-center study with a short-term follow-up.…”

“…The clinical significance of this lesion has been controversial and is largely determined by the clinical features of the case. [6][7][8][9][10][11][12] Most of the studies on borderline changes have been conducted in deceased donor transplant setups. 3 Mirza Naqi Zafar, depending on the source of the donor organ.…”