|
Parameter |
Nephrotoxicity |
Rejection |
|
History |
Donor > 50 years old or hypotensive Prolonged kidney preservation
Prolonged anastomosis time
Concomitant nephrotoxic drugs |
Anti-donor immune response
Retransplant patient |
|
Clinical |
Often > 6 weeks postopb
Prolonged initial nonfunction
(acute tubular necrosis) |
Often < 4 weeks postopb
Fever > 37.5°C
Weight gain > 0.5 kg
Graft swelling and tenderness
Decrease in daily urine volume
> 500 mL (or 50%) |
|
Laboratory |
CyA serum trough level > 200 ng/mL Gradual rise in Cr (< 0.15 mg/dL/day)a
Cr plateau < 25% above baseline
BUN/Cr ≥ 20 |
CyA serum trough level < 150 ng/mL Rapid rise in Cr (> 0.3 mg/dL/day)a
Cr > 25% above baseline
BUN/Cr < 20 |
|
Biopsy |
Arteriolopathy (medial hypertrophya, hyalinosis, nodular deposits, intimal thickening, endothelial vacuolization, progressive scarring)
Tubular atrophy, isometric vacuolization, isolated calcifications
Minimal edema
Mild focal infiltratesc
Diffuse interstitial fibrosis, often striped form |
Endovasculitisc (proliferationa, intimal arteritisb, necrosis, sclerosis)
Tubulitis with RBCb and WBCb casts, some irregular vacuolization
Interstitial edemac and hemorrhageb
Diffuse moderate to severe mononuclear infiltratesd
Glomerulitis (mononuclear cells)c |
|
Aspiration Cytology |
CyA deposits in tubular and endothelial cells
Fine isometric vacuolization of tubular cells |
Inflammatory infiltrate with mononuclear phagocytes, macrophages, lymphoblastoid cells, and activated T-cells
These strongly express HLA-DR antigens |
|
Urine Cytology |
Tubular cells with vacuolization and granularization |
Degenerative tubular cells, plasma cells, and lymphocyturia > 20% of sediment |
Manometry
Ultrasonography |
Intracapsular pressure < 40 mm Hgb
Unchanged graft cross sectional area |
Intracapsular pressure > 40 mm Hgb
Increase in graft cross sectional area
AP diameter ≥ Transverse diameter |
|
Magnetic Resonance Imagery |
Normal appearance |
Loss of distinct corticomedullary junction, swelling image intensity of parachyma approaching that of psoas, loss of hilar fat |
|
Radionuclide Scan |
Normal or generally decreased perfusion
Decrease in tubular function
(131 I-hippuran) > decrease in perfusion
(99m Tc DTPA) |
Patchy arterial flow
Decrease in perfusion > decrease in tubular function
Increased uptake of Indium 111 labeled platelets or Tc-99m in colloid |
|
Therapy |
Responds to decreased cyclosporine |
Responds to increased steroids or antilymphocyte globulin |
