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Rejeição Aguda
Gustavo FerreiraMédico-Residente Nefrologia
HCFMUSP
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Wolfe, N Engl J Med 1999
4,00
2,84
1,00
0,32
0,25
Dias após o transplante
Risco Relativo de Morte
0 106183 365 548
n = 23.275Riscoigual
%
50
40
30
20
10
1 3 6 12 2 3 4 5 6 7 8 9 101112meses anos
Rejeição aguda
Infecções virais
Diabetes mellitus
Cronologia dos Eventos no Transplante Renal
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Evolução dos Imunossupressores
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Cronologia dos Eventos no Transplante Renal%
50
40
30
20
10
1 3 6 12 2 3 4 5 6 7 8 9 10 11 12meses anos
Cronologia dos Eventos no Transplante Renal
Rejeição aguda
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Tempo para Ocorrência de Rejeição Aguda (Kaplan-Meier)
dias pós transplante
0 30 60 90 120 180 240 300 360
0
0,1
0,2
0,3
0,4
0,5 n = 141
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dias após o transplante
0 30 60 90 180 240 300 3600
0,1
0,2
0,3
0,4
0,5
0,6
0,71997
1998
1999
2000
Rejeição Aguda no Primeiro Ano
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Rejeição e Imunossupressão
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0
1
2
3
4
5
6Risc
o Relativ
o
96-97 94-95 92-93 90-91 88-89
Sem Rejeição
Biênios
Meier Kriesche, Transplantation 2000
Com Rejeição
5,24,98
3,4
2,351,67
n = 63.045
Risco de Perda Tardia em Pacientes com Rejeição Aguda
1,53 1,37 1,31 1,14 1
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Sobrevida do Enxerto(excluídos os óbitos com rim funcionante)
1997 - 2000
dias pós-transplante
0 365 730 1095 1460 1825 2190 2555 29200
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0sem Rejeição Aguda
n = 305p = 0,01
com Rejeição Aguda
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Immunofluorecence microscopy shows C4d deposits along peritubular capillaries (green, arrowheads) and collagen type IV accumulations along tubular basement membranes (red, arrows). A tangentially cut glomerulus (G) only shows non-specific C4d deposits in mesangial regions. Double incubations performed on fresh frozen tissue sample
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In renal allograft biopsies, C4d can be detected in association with different histological changes and even in the setting of normal histology. Statistical significant is the correlation between C4d and ‘acute cellular rejection’, in particular transplant glomerulitis. Only a minority of C4d-positive biopsies represent ‘pure humoral rejection’.
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Criteria for acute antibody-mediated rejection in renal allografts include 3 cardinal features
1. Morphologic evidence of acute tissue injury, such as: (a) acute tubular injury, (b) neutrophils and/or mononuclear cells in peritubular capillaries and/or glomeruli, and/or capillary thrombosis; or (c) intimal arteritis/fibrinoid necrosis/intramural or transmural inflammation in arteries.
2. Immunopathologic evidence for antibody action, such as: (a) C4d and/or (rarely) immunoglobulin in peritubular capillaries or (b) immunoglobulin and complement in arterial fibrinoid necrosis
3. Serologic evidence of circulating antibodies to donor HLA or other anti-donor endothelial antigens.