Which of the following symptoms indicate acute rejection of a transplanted kidney?

Kidney donors

More than one half of donated kidneys come from previously healthy, brain-dead people. About one third of these kidneys are marginal, with physiologic or procedure-related damage, but are used because demand is so great.

More kidneys from non–heart-beating donors (called donation-after-cardiac-death [DCD] grafts) are being used. These kidneys may have been damaged by ischemia before the donor's death, and their function is often impaired because of acute tubular necrosis; however, over the long term, they seem to function as well as kidneys from donors that meet standard criteria (called standard criteria donors [SCD]).

The remaining donated kidneys (about another 40%) come from living donors; because of limited supply, allografts from carefully selected living unrelated donors are being increasingly used. Living donors relinquish reserve renal capacity, may put themselves at risk of procedural and long-term morbidity, and may have psychologic conflicts about donation; therefore, they are evaluated for normal bilateral renal function, absence of systemic disease, histocompatibility, emotional stability, and ability to give informed consent. Hypertension, diabetes, and cancer in prospective living donors usually preclude kidney donation.

Kidney exchange programs often match a prospective donor and recipient who are incompatible with other similar incompatible pairs. When many such pairs are identified, chain exchanges are possible, greatly increasing the potential for a good match between recipient and donor.

If ABO matching is not feasible, sometimes ABO-incompatible transplantation can be done; with careful selection of donors and recipients and with pretransplant treatment (plasma exchange and/or IV immune globulins [IVIG]), outcomes can be comparable to those of ABO-compatible transplantation.

Procedure

The donor kidney is removed during a standard or robotic-assisted laparoscopic (or rarely, an open) procedure, perfused with cooling solutions containing relatively large concentrations of poorly permeating substances (eg, mannitol, hetastarch) and electrolyte concentrations approximating intracellular levels, then stored in an iced solution. Kidneys preserved this way usually function well if transplanted within 24 hours. Although not commonly used, continuous pulsatile hypothermic perfusion with an oxygenated, plasma-based perfusate can extend ex vivo viability up to 48 hours.

For recipients, dialysis may be required before transplantation to ensure a relatively normal metabolic state, but living-donor allografts appear to survive slightly better in recipients who have not begun long-term dialysis before transplantation.

Recipient nephrectomy is usually not required unless native kidneys are infected.

Whether transfusions are useful for patients who have anemia and are anticipating an allograft is unclear; the leading evidence suggests that transfusions can sensitize patients to alloantigens and thus should typically be avoided if possible. However, allografts may survive better in recipients who receive transfusions but do not become sensitized, possibly because transfusions induce some form of tolerance.

The transplanted kidney is usually placed in the iliac fossa. Renal vessels are anastomosed to the iliac vessels, and the donor ureter is implanted into the bladder or anastomosed to the recipient ureter. Vesicoureteral reflux occurs in about 30% of recipients, but usually without adverse effects.

Immunosuppressive regimens vary (see table ). An induction agent (eg, antithymocyte globulin, alemtuzumab) is started intraoperatively in almost all kidney transplant recipients. Commonly, calcineurin inhibitors are begun immediately after transplantation in doses titrated to minimize toxicity and rejection while maintaining trough blood levels high enough to prevent rejection. On the day of transplantation, IV or oral corticosteroids are started; dose is tapered over the following weeks depending on the protocol used.

Complications of Kidney Transplantation

(See also .)

Prognosis for Kidney Transplantation

Most rejection episodes and other complications occur within 3 to 4 months after transplantation; most patients then return to more normal health and activity but must take maintenance doses of immunosuppressants indefinitely.

At 1 year after kidney transplantation, survival rates are

• Living-donor grafts: 98% (patients) and 94% (grafts)

• Deceased-donor grafts: 95% (patients) and 88% (grafts)

Subsequent annual graft loss rates are 3 to 5% with a living-donor graft and 5 to 8% with a deceased-donor graft.

Among patients whose graft survives the first year, half die of other causes (eg, cardiovascular disease, infection) with the graft functioning normally; half develop chronic allograft nephropathy with the graft malfunctioning in 1 to 5 years. Rates of late failure are higher for patients with African ancestry.

Doppler ultrasonographic measurement of peak systolic and minimal end-diastolic flow in renal segmental arteries ≥ 3 months after transplantation may help assess prognosis.

The best clinical predictor remains

• Serial determination of serum creatinine

In a specific patient, the most recently obtained creatinine levels should be compared with previous levels; a sudden increase in creatinine indicates the need to look for rejection or another problem (eg, vascular compromise, obstruction of the ureter). Ideally, serum creatinine should be normal in all posttransplant patients 4 to 6 weeks after kidney transplantation.

What are the signs of kidney rejection in a transplanted kidney?

Which finding would indicate an acute rejection of transplanted kidney?

What are the signs of transplant rejection?

What is acute rejection after kidney transplant?