October 28, 2024, Immune Tolerance
Throughout, rejection has been a common concern following transplantation. Compared to acute rejection, chronic rejection is more challenging to diagnose and treat and is closely linked to the long-term survival of kidney allografts. If chronic rejection is not diagnosed and treated promptly, it frequently leads to a series of complications, including hypertension and proteinuria, resulting in further irreversible damage and loss of graft function.
What Is Chronic Rejection?
Chronic kidney allograft rejection is defined as rejection occurring more than 3 to 6 months after transplantation, characterized by a progressive decline in kidney function, hypertension, and proteinuria, ultimately leading to kidney failure, a return to dialysis, or the need for retransplantation. The onset of chronic rejection is more insidious and less aggressive than acute rejection, making it less likely to be noticed by patients. Some patients who fail to follow up regularly often miss the optimal treatment window because they cannot detect the condition early.
What Factors Can Trigger Chronic Rejection?
The precise pathogenesis of chronic rejection remains incompletely understood in medicine. It is recognized that numerous immunological and non-immunological factors are closely associated with triggering chronic rejection. Immunological factors include human leukocyte antigen (HLA) mismatch, acute rejection, subclinical rejection, and chronic underdosing of immunosuppressants. Non-immunological factors include delayed graft function, immunosuppressive nephrotoxicity, cytomegalovirus (CMV) and polyomavirus (e.g., BK virus [BKV]) infections, hyperlipidemia, hypertension, and proteinuria.
Moreover, in addition to the aforementioned factors, chronic rejection is also closely linked to medication adherence. Patients who fail to adhere to prescribed medications or miss follow-up appointments often experience irreversible kidney damage due to prolonged insufficient immunosuppressant doses or acute and chronic rejection triggered by viral infections.
How Should Chronic Rejection Be Managed?
Managing chronic rejection poses significant diagnostic and therapeutic challenges. Before establishing a diagnosis, physicians must exclude other causes of kidney damage, such as obstruction, reflux, renal artery stenosis, infection, and acute rejection, and differentiate it from drug-induced nephrotoxicity and recurrence of primary kidney disease. Scheduled renal biopsies can identify underlying lesions early, playing a critical role in the early diagnosis and timely intervention of chronic rejection.
Patients with chronic rejection require comprehensive treatment, including adjusting immunosuppressants, effectively managing blood pressure, correcting dyslipidemia, and improving renal blood flow and proteinuria. In principle, if some patients with early-stage chronic rejection receive timely treatment under an optimal immunosuppressive regimen and comprehensive care, kidney allograft function may remain stable over an extended period or the disease’s progression may be slowed. Once clinical symptoms such as proteinuria and hypertension become pronounced, management becomes considerably more challenging.
Therefore, for kidney transplant patients, regular follow-up visits and scheduled renal allograft biopsies are crucial, enabling doctors to promptly identify issues, reassess the immunosuppressive regimen based on disease progression, and address chronic rejection effectively.
Written by | Sun Jiajia, Edited by | Sun Jiajia, Photography | G.T.
This article is an original publication of the “Kidney Transplantation, Zhongshan Hospital, Fudan University” WeChat public account. Reproduction requires authorization from this account and the original author, with proper attribution. To care for your kidneys, begin by following the “Kidney Transplantation, Zhongshan Hospital, Fudan University” WeChat public account. You can also click [Read the Original] to explore What You Should Be Aware of After Kidney Transplantation (Part 4): Hyperuricemia.
