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What is the cause for kidney rejection in transplantation?

Q: My brother had a kidney transplant from an unrelated donor in Maharashtra. Post transplantation he was fine and was on immunosuppresive drugs like panimum and Mycept. For one and half years he was alright and then suddenly he developed nausea, vomiting, and a rise in creatinine and urea. His creatinine was 14.42 and BUN was around 200. We took him to the doctor who did the transplant and there he was on dialysis. After 8 dialyses, his creatinine was 17 and BUN was 180. The doctor told us he was in acute rejection and we were referred to doctors in Bangalore. We came to Bangalore and he is now on continuous dialysis. Recently he developed a fast heart rate and we were told that he was in supraventricular tachycardia. He was on digoxin and metoprolol. Sir, my question is how and what is the cause of the rejection? I was told that his ultrasound and biopsy results were normal. He was given some IOR CD3 (OKT3) injection too. He was given 7 doses of it and there was no improvement in his symptoms. What should we do from now on and what will be the survival rate of my brother?

A:It appears a quite complex case of a failed unrelated kidney transplant. It is unclear why this transplant has failed since you have mentioned that biopsy was reportedly normal. However, on the quite contrary, you have mentioned that he was administered OKT3 which is a strong anti-rejection medicine. Rejection is recipient's immune response to a foreign body (in this case unrelated kidney) and therefore body's defence tries to destroy that foreign body. To prevent rejection, kidney transplant recipient is placed on anti-rejection medicines to knock down his immune system. Rejection can be of varying degrees of severity depending on a variety of factors. One factor is degree of mismatch between donor and recipient blood types. Since the biopsy results have not been provided, it can not be stated whether or not this patient will recover his kidney function. If his kidney is completely destroyed by rejection, he will need to be on dialysis. The survival rates of such patients are not inferior to dialysis patients. But certain patients in this subgroup may require removal of this transplanted kidney since ongoing rejection continues to cause disabling symptoms.

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