Rejection Challenges: Diagnosis and Management

This chapter proposes a summary of the current understanding of kidney allograft rejection, evolving from a traditional conceptualization of discrete episodes to a model that recognizes phases of immune activation directed toward the allograft. This starts with detection of well-understood forms of early T cell-mediated rejection (TCMR) or antibody-mediated rejection (AMR) that typify initiation of allograft directed immune injury, and maturation to more complex and chronic forms of rejection that are characterized most often by integrated T and B responses and memory. The risk of progression to chronic forms of rejection may depend on the degree with which alloimmune responsiveness is consistently subdued by immunosuppressant medication, but also the degree with which either the innate and cognate effector responses are secondarily activated or by which adaptive, regulatory responses restrain inflammation.