Which of the following is the MOST appropriate initial treatment for acute rejection of a renal allograft?A. 3.375 g piperacillin/tazobactam
Although there are over 10 definitions of DGF1.
Correct Answer: C
Acute rejection typically presents in the first 6 months after renal transplantation and is cell mediated. The incidence of acute rejection has declined with current practices in induction and maintenance of immunosuppression. There are two histological forms of acute rejection, Acute T cell–mediated rejection and acute antibody-mediated rejection. Risk factors include human leukocyte antigen (HLA) mismatches, blood group incompatibility, prolonged cold ischemia time, DGF, and patients with previous episodes of rejection. Most patients are asymptomatic; the first sign is usually a rise in serum creatinine. Worsening hypertension and proteinuria >1 g/d are other signs of acute rejection. Diagnosis is confirmed with allograft biopsy. Treatment is with pulse methylprednisolone in most centers, with the dose and duration of pulse therapy depending on the grade of rejection. Maintenance immunosuppression therapy may also be intensified (eg, aim for higher tacrolimus levels). Antithymocyte globulin is typically used as a secondline agent and is coadministered with glucocorticoid therapy in higher grade rejection or rejection refractory to glucocorticoid pulse therapy. The expected reversal rate for a first episode of acute rejection is 60% to 70% with this regimen. Plasmapharesis can be effective in antibody-mediated rejection, but it is not first-line therapy. Therapy success is indicated by increases in urine output and a decrease in serum creatinine within 5 days of initiating treatment.