Acute humoral rejection (AHR) of the kidney allograft is characterized by several clinical features that are of importance. For instance there is allograft dysfunction accompanied by high levels of creatinine with some cases experiencing reduced urine output. AHR is experienced almost any time but it is common in the initial weeks after transplantation or if there is reduced immunosuppression.
Individuals who may be having prior sensitization through transplant, pregnancy or blood transfusion have a higher risk of developing acute cell-mediated rejection. Acute humoral rejection usually presents in form of acute cell injury which is indicated by â€œacute tubular injury, neutrophil margination, thrombotic microangiopathy, and/or arterial fibrinoid necrosisâ€ (McKay & Steinberg, 2010, p. 175).
The C4d are also present in the peritubular capillaries coupled with presence of HLA among any other antigen that may be present in circulation. Whenever at least two of the above characteristics are identified, it becomes important to be â€˜suspiciousâ€™ of the presence of acute humoral rejection. On viewing the biopsy via light microscopy, marginating neutrophils are located in the peritubular capillaries, which are already dilated. Endothelial injury as well as glomerular thrombosis not to mention the interstitial capillaries present with injury. A common feature of the larger arteries is the transmural fibrinoid necrosis and infiltration of leukocytes in some cases. It is also possible to witness interstitial edema and hemorrhage with mononuclear inflammation occurring only if acute cellular rejection occurs at the same time.
AHR is classified into class I, class II and class II as per the most current Banff criteria. Class I acute humoral rejectionâ€™s biopsy is characterized by acute tubular injury and hardly any inflammation. Capillary glomerulitis is the key characteristic of AHR class II whereas the small arteries experience transmural fibrinoid necrosis in AHR class III. In all the classes of acute humoral rejection, macrophages are commonly found and the C4 complement is also found in the tissue and may last for 7 to 10 days.
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