Figure 95

Histologic features of acute cellular rejection. A, Mild tubulitis. B, Moderate to severe tubulitis. Acute rejection episodes may occur as early as 5 to 7 days, but are generally seen between 1 and 4 weeks after transplantation. The classic acute rejection episode of the earlier era (ie, azathioprine-prednisolone) was accompanied by swelling and tenderness of the kidney and the onset of oliguria with an associated rise in serum creatinine; these symptoms were usually accompanied by a significant fever. However, in patients who have been treated with cyclosporine, the clinical features of an acute rejection are really quite minimal in that there is perhaps some swelling of the kidney, usually no tenderness, and there may be a minimal to moderate degree of fever. Because such an acute rejection may occur at a time when there is a distinct possibility of r

acute cyclosporine toxicity, the differentiation between the two entities may be extremely difficult.

The differential diagnosis of acute rejection, acute tubular necrosis, and cyclosporine nephrotoxicity may be difficult, especially in the early posttransplant period when more than one cause of dysfunction can occur together [2]. Knowledge of the natural history of several clinical entities is extremely helpful in limiting the differential diagnosis. Reversible medical and mechanical causes should be excluded first. Percutaneous biopsy of the renal allograft using real-time ultrasound guide is a safe procedure. It provides histologic confirmation of the diagnosis of rejection, aids in the differential diagnosis of graft dysfunction, and allows for assessment of the likelihood of a response to antirejection treatment.

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