Cyclosporine toxicity and renal allograft rejection can both result in renal impairment in the renal transplant patient. Certain clinical and laboratory findings can help distinguish between these two conditions.
Favor Cyclosporine Toxicity |
Favor Renal Allograft Rejection |
often > 6 weeks post transplant |
often < 4 weeks post transplant |
concomitant nephrotoxic drugs |
retransplant patient |
donor > 50 years of age, donor hypotensive, prolonged preservation of donor kidney, prolonged anastomosis time, prolonged initial nonfunction |
antidonor immune response |
afebrile without graft swelling or tenderness |
fever > 37.5°C with graft swelling and tenderness |
cyclosporine trough serum levels > 200 ng/mL |
cyclosporine trough serum level < 150 ng/mL |
rise in serum creatinine gradual (< 0.15 mg/dL per day); plateau < 25% above baseline |
rise in serum creatinine rapid (> 0.3 mg/dL per day); plateau > 25% above baseline |
BUN to creatinine ratio >= 20 |
BUN to creatinine ratio < 20 |
arteriolopathy on renal biopsy |
endovasculitis on renal biopsy |
tubular atrophy, isometric vacuolization and isolated calcifications on renal biopsy |
glomerulitis and tubulitis on renal biopsy |
no or minimal edema on renal biopsy; diffuse interstitial fibrosis |
interstitial edema and hemorrhage on renal biopsy |
mild focal infiltrates on renal biopsy |
diffuse inflammatory mononuclear cell infiltrate on renal biopsy |
intracapsular pressure < 40 mm Hg on manometry |
intracapsular pressure > 40 mm Hg on manometry |
graft cross sectional area unchanged on ultrasound |
graft cross sectional area increased, with AP diameter >= transverse diameter |
MRI appearance normal |
MRI shows loss of distinct cortico-medullary junction with swelling |
radionuclide scan shows normal or generally decreased perfusion |
radionuclide scan shows patchy arterial flow |
radionuclide scan shows a decrease in tubular function > decrease in perfusion |
radionuclide scan shows a decrease in tubular function < decrease in perfusion; increased uptake of Indium 111 labeled platelets or Tc-99m in colloid |
responds to decrease in cyclosporine dose |
responds to an increase in steroids or antilymphocyte globulin |
where:
• Arteriolopathy involves medial hypertrophy, hyalinosis, nodular deposits, intimal thickening, endothelial vascularization, progressive scarring.
• Endovasculitis involves proliferation, intimal arteritis, necrosis and sclerosis.
• A radionuclide scan for tubular function uses 131I-hippurate, while for perfusion uses 99m-Tc DTPA.
Specialty: Nephrology, Clinical Laboratory
ICD-10: ,