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Rejection in Kidney Transplants
Ghaneh Fananapazir, MD, FSAR, FSRU, FSABI
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Definitions

              • Hyperacute rejection
                • Occurs from preformed antibody or ABO incompatibility
                • Rarely occurs and never imaged
              • Acute rejection
                • Occurs most often within first 6 months after transplantation
                • Causes inflammation of glomeruli, tubules, arteries, and interstitium
              • Interstitial fibrosis and tubular atrophy (IF/TA)
                • Formerly called chronic rejection
                • Greatest cause of death-censored graft failure after 1 year
                • Can be due to prior episodes of rejection
                • Can also be due to nonrejection causes of fibrosis, such as hypertension, calcineurin inhibitor toxicity, and chronic infection

            IMAGING

            • General Features

              • CT Findings

                • MR Findings

                  • Ultrasonographic Findings

                    • Image-Guided Biopsy

                      • Nuclear Medicine Findings

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • Staging, Grading, & Classification

                              • Microscopic Features

                                CLINICAL ISSUES

                                • Presentation

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Image Interpretation Pearls

                                        Selected References

                                        1. Fananapazir G et al: Sonographically diagnosed urothelial thickening in kidney allografts: a noninvasive and clinically highly relevant marker for the detection of acute rejection. AJR Am J Roentgenol. 215(1):148-52, 2020
                                        2. Gokalp C et al: Acoustic radiation force impulse elastography may predict acute rejection in kidney transplantation. Transplant Proc. 52(10):3097-102, 2020
                                        3. Goyal A et al: Evaluation of the graft kidney in the early postoperative period: performance of contrast-enhanced ultrasound and additional ultrasound parameters. J Ultrasound Med. ePub, 2020
                                        4. Phillips CH et al: Clinical significance of renal allograft urothelial thickening identified by ultrasound. J Ultrasound Med. ePub, 2020
                                        5. Jehn U et al: Renal allograft rejection: noninvasive ultrasound- and MRI-based diagnostics. Contrast Media Mol Imaging. 2019:3568067, 2019
                                        6. Shehata M et al: Computer-aided diagnostic system for early detection of acute renal transplant rejection using diffusion-weighted MRI. IEEE Trans Biomed Eng. 66(2):539-52, 2019
                                        7. Wang W et al: Combination of functional magnetic resonance imaging and histopathologic analysis to evaluate interstitial fibrosis in kidney allografts. Clin J Am Soc Nephrol. 14(9):1372-80, 2019
                                        8. Aghighi M et al: Ferumoxytol is not retained in kidney allografts in patients undergoing acute rejection. Mol Imaging Biol. 20(1):139-49, 2018
                                        9. Mueller-Peltzer K et al: Vascular rejection in renal transplant: diagnostic value of contrast-enhanced ultrasound (CEUS) compared to biopsy. Clin Hemorheol Microcirc. 69(1-2):77-82, 2018
                                        10. Goldberg RJ et al: Acute and chronic allograft dysfunction in kidney transplant recipients. Med Clin North Am. 100(3):487-503, 2016
                                        11. Spatola L et al: Doppler ultrasound in kidney diseases: a key parameter in clinical long-term follow-up. J Ultrasound. 19(4):243-50, 2016
                                        12. Lanzman RS et al: Kidney transplant: functional assessment with diffusion-tensor MR imaging at 3T. Radiology. 266(1):218-25, 2013
                                        13. Han F et al: The significance of BOLD MRI in differentiation between renal transplant rejection and acute tubular necrosis. Nephrol Dial Transplant. 23(8):2666-72, 2008
                                        14. Thoeny HC et al: Functional evaluation of transplanted kidneys with diffusion-weighted and BOLD MR imaging: initial experience. Radiology. 241(3):812-21, 2006
                                        15. Chow L et al: Power Doppler imaging and resistance index measurement in the evaluation of acute renal transplant rejection. J Clin Ultrasound. 29(9):483-90, 2001
                                        Related Anatomy
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                                        Related Differential Diagnoses
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                                        References
                                        Tables

                                        Tables

                                        KEY FACTS

                                        • Terminology

                                          • Imaging

                                            • Top Differential Diagnoses

                                              • Pathology

                                                • Clinical Issues

                                                  TERMINOLOGY

                                                  • Definitions

                                                    • Hyperacute rejection
                                                      • Occurs from preformed antibody or ABO incompatibility
                                                      • Rarely occurs and never imaged
                                                    • Acute rejection
                                                      • Occurs most often within first 6 months after transplantation
                                                      • Causes inflammation of glomeruli, tubules, arteries, and interstitium
                                                    • Interstitial fibrosis and tubular atrophy (IF/TA)
                                                      • Formerly called chronic rejection
                                                      • Greatest cause of death-censored graft failure after 1 year
                                                      • Can be due to prior episodes of rejection
                                                      • Can also be due to nonrejection causes of fibrosis, such as hypertension, calcineurin inhibitor toxicity, and chronic infection

                                                  IMAGING

                                                  • General Features

                                                    • CT Findings

                                                      • MR Findings

                                                        • Ultrasonographic Findings

                                                          • Image-Guided Biopsy

                                                            • Nuclear Medicine Findings

                                                              • Imaging Recommendations

                                                                DIFFERENTIAL DIAGNOSIS

                                                                  PATHOLOGY

                                                                  • Staging, Grading, & Classification

                                                                    • Microscopic Features

                                                                      CLINICAL ISSUES

                                                                      • Presentation

                                                                        • Natural History & Prognosis

                                                                          • Treatment

                                                                            DIAGNOSTIC CHECKLIST

                                                                            • Image Interpretation Pearls

                                                                              Selected References

                                                                              1. Fananapazir G et al: Sonographically diagnosed urothelial thickening in kidney allografts: a noninvasive and clinically highly relevant marker for the detection of acute rejection. AJR Am J Roentgenol. 215(1):148-52, 2020
                                                                              2. Gokalp C et al: Acoustic radiation force impulse elastography may predict acute rejection in kidney transplantation. Transplant Proc. 52(10):3097-102, 2020
                                                                              3. Goyal A et al: Evaluation of the graft kidney in the early postoperative period: performance of contrast-enhanced ultrasound and additional ultrasound parameters. J Ultrasound Med. ePub, 2020
                                                                              4. Phillips CH et al: Clinical significance of renal allograft urothelial thickening identified by ultrasound. J Ultrasound Med. ePub, 2020
                                                                              5. Jehn U et al: Renal allograft rejection: noninvasive ultrasound- and MRI-based diagnostics. Contrast Media Mol Imaging. 2019:3568067, 2019
                                                                              6. Shehata M et al: Computer-aided diagnostic system for early detection of acute renal transplant rejection using diffusion-weighted MRI. IEEE Trans Biomed Eng. 66(2):539-52, 2019
                                                                              7. Wang W et al: Combination of functional magnetic resonance imaging and histopathologic analysis to evaluate interstitial fibrosis in kidney allografts. Clin J Am Soc Nephrol. 14(9):1372-80, 2019
                                                                              8. Aghighi M et al: Ferumoxytol is not retained in kidney allografts in patients undergoing acute rejection. Mol Imaging Biol. 20(1):139-49, 2018
                                                                              9. Mueller-Peltzer K et al: Vascular rejection in renal transplant: diagnostic value of contrast-enhanced ultrasound (CEUS) compared to biopsy. Clin Hemorheol Microcirc. 69(1-2):77-82, 2018
                                                                              10. Goldberg RJ et al: Acute and chronic allograft dysfunction in kidney transplant recipients. Med Clin North Am. 100(3):487-503, 2016
                                                                              11. Spatola L et al: Doppler ultrasound in kidney diseases: a key parameter in clinical long-term follow-up. J Ultrasound. 19(4):243-50, 2016
                                                                              12. Lanzman RS et al: Kidney transplant: functional assessment with diffusion-tensor MR imaging at 3T. Radiology. 266(1):218-25, 2013
                                                                              13. Han F et al: The significance of BOLD MRI in differentiation between renal transplant rejection and acute tubular necrosis. Nephrol Dial Transplant. 23(8):2666-72, 2008
                                                                              14. Thoeny HC et al: Functional evaluation of transplanted kidneys with diffusion-weighted and BOLD MR imaging: initial experience. Radiology. 241(3):812-21, 2006
                                                                              15. Chow L et al: Power Doppler imaging and resistance index measurement in the evaluation of acute renal transplant rejection. J Clin Ultrasound. 29(9):483-90, 2001