Contemporary Renal Replacement Therapy

Q 1. Acute allograft rejection is the graft rejection that occurs due to T cell-mediated damage to the allograft that results due to the cellular infiltrates which directly damage the organ. Acute graft rejection occurs due to the intense cellular and humoral response of the body over the graft that leads to the loss of the graft (Dogan et al. 2018; Benichou et al. 2017). Acute allograft rejection is the most prevalent and serious issue that ultimately lead to the rejection of the graft. The two processes that lead to the graft loss due to graft allograft rejection include acute cellular rejection that includes A-grade and B-grade, On the other hand, acute humoral rejection includes Anti-HLA antibodies and vascular injury (Martinu et al. 2011). The acute rejection occurs in days or week after the transplantation due to the lymphocyte action that leads to the negative effect over the graft. The chronic rejection is directly associated with the rejection after month or years due to chronic inflammation that leads to the immunopathogenesis chronic rejection (Vaillant and Mohseni, 2020). Acute rejection occurs in every graft in minor or major extent except the identical twins and immunosuppression can help to decrease the acute graft rejection. Chronic rejection occurs in the long term loss of functionality related to the organ that leads to the fibrosis followed by graft rejection. Both of the theses rejection differs in the time and intensity of the body immune response against the graft that leads to the rejection (Bhatti and Usman, 2015).

Q 2. The pathophysiology of acute allograft rejection is associated with the elevate level of the HLA class 1 and 2 in the graft that leads to the infiltration of the CD8+ T cells. The infiltration of the CD4+ T cells leads to the recruitment of the effector cell that is related to the damage of the graft that occur due CD8+ T cells, macrophage, natural killer cells and B cells. The graft foreign antigen is recognised by the antigen-presenting cell that leads to the activation of the adaptive immune system which leads to acute rejection (Cooper, 2020; Lamarche et al. 2016). The simple steps that lead to the acute allograft rejection are graft implemented to the epidermis after 3 to 7 days revascularization occur which after 7-10 lead to the cellular infiltration and ultimately in 10-14 days thrombosis and necrosis of the graft occur that lead to the rejection. In the acute allograft rejection, two are the major pathways of rejection that includes CD4+ T cells or the anti-donor antibodies that are generated after the transplant (Benzimra et al. 2017; Roden et al. 2017). The acute allograft rejection is considered to be the reversible cell medicated rejection that leads to the different symptoms in the patient that includes fever, fluctuation in mental state and abnormal body functioning. Allograft rejection occurs when the graft is transferred by the non-identical twins which lead to the increasing changes of the negative immune response toward the graft that lead to the necrosis (Eikmans et al. 2019).

Q 3. The management of the acute allograft rejection starts with the use of immunosuppression drug that is important to reduce the activity of the immune system. The less active immune system increases the survival chances of the graft. The immunosuppressive drug therapy is the first line of treatment that is used by the health care professional to decrease the chances of graft rejection (Vollmers et al. 2015; Claeys and Vermeire, 2019). Different drugs are used in the suppression process that includes Polyclonal anti-lymphocyte antibodies, monoclonal anti-lymphocyte antibodies and interleukins. The therapy starts with the induction process that slowly introduces the immunosuppressive in the body followed by the maintenance of the normal amount of regular regimens that help in decrease rejection (Saldanha et al. 2018). Another method that can help in the management of acute allograft rejection is the Polyclonal anti-T-lymphocyte antibody therapy that is considered to be important to deal with rejection. Polyclonal anti-T-lymphocyte antibody therapy includes the infusion of the horse or rabbit synthesized antibodies against the T cell involved in the rejection process that helps to decrease the episode of the allograft rejection. The dose is prescribed as per the body weight and patient current health status to reduce the chances of side effect that can occur due to the over immunosuppression. The Polyclonal anti-T-lymphocyte antibody therapy requires continuous monitoring of the patient to identify the impact of the therapy over the individual to improve the treatment process (Machado et al. 2018; Kühne et al. 2017).

Q 4. One of the educational points that can help Kerry is about the different precautions that are important for her to be safe and decrease chances of rejection. The educational intervention for the patient undergone transplantation is important to improve the understanding of the patient concerning the precautions method to improve health. The educational intervention will include information about the medication, risk factor and precaution that are important to stabilize the health status (Hunt et al. 2018). The article presented by Banach et al. (2016) and Mohamed and Mostafa, (2018) discuss that infection is one of the major issues that lead to the rejection of the transplanted organ. Bacterial or fungal infection increases the complication of the patient by deteriorating health of the patient. The patient education plan should include the right information about the infection control strategies that will help to reduce the chances of infection. Another aspect that will be covered in the educational point of Kerry is the adherence to the immunosuppressive drug that is important to decrease the activity of the immune system to decrease chances of graft rejection. The article presented Mathes et al. (2017) and Myaskovsky et al. (2018) added those immunosuppressive drugs are very important for the patient undergone transplantation process to increase the chances of survival of the graft. The patient should be aware of the utility, dose and side effect of the mediation so that adherence to the medication can be improved. These two educational aspects will be delivered by partnering with the pharmacist and it will help Kerry to improve the lifestyle that will help to decrease the chances of graft rejection.

References for Acute Allograft Rejection

Dogan, N., Hüsing-Kabar, A., Schmidt, H. H., Cicinnati, V. R., Beckebaum, S. and Kabar, I. 2018. Acute allograft rejection in liver transplant recipients: Incidence, risk factors, treatment success, and impact on graft failure. The Journal of International Medical Research, vol. 46, no. 9, pp. 3979–3990. https://doi.org/10.1177/0300060518785543

Martinu, T., Pavlisko, E. N., Chen, D. F. and Palmer, S. M. 2011. Acute allograft rejection: Cellular and humoral processes. Clinics in chest medicinevol. 32, no. 2, pp. 295–310. https://doi.org/10.1016/j.ccm.2011.02.008

Benichou, G., Gonzalez, B., Marino, J., Ayasoufi, K. and Valujskikh, A. 2017. Role of memory t cells in allograft rejection and tolerance. Frontiers in Immunology, vol. 8, no. 170, pp. 1-9. https://doi.org/10.3389/fimmu.2017.00170

Vaillant, A. A. and Mohseni, M. 2020. Chronic transplantation rejection. Treasure Island, United Kingdom: StatPearls Publishing.

Bhatti, A. B., and Usman, M. 2015. Chronic renal transplant rejection and possible anti-proliferative drug targets. Cureus7(11), 1-15. https://doi.org/10.7759/cureus.376

Cooper, J. E. 2020. Evaluation and treatment of acute rejection in kidney allografts. Clinical Journal of the American Society of Nephrology, vol. 15, pp. 430–438. https://doi.org/10.2215/cjn.11991019 

Lamarche, C., Côté, J.-M., Sénécal, L. and Cardinal, H. 2016. Efficacy of acute cellular rejection treatment according to Banff score in kidney transplant recipients. Transplantation Direct, vol. 2, no. 12, pp. 1-7. https://doi.org/10.1097/txd.0000000000000626 

Eikmans, M., Gielis, E. M., Ledeganck, K. J., Yang, J., Abramowicz, D. and Claas, F. 2019. Non-invasive biomarkers of acute rejection in kidney transplantation: Novel targets and strategies. Frontiers in Medicine, vol. 5, no. 358, pp. 1-7. https://doi.org/10.3389/fmed.2018.00358

Benzimra, M., Calligaro, G. L. and Glanville, A. R. 2017. Acute rejection. Journal of Thoracic Disease, vol. 9, no. 12, 5440–5457. https://doi.org/10.21037/jtd.2017.11.83

Roden, A. C., Aisner, D. L., Allen, T. C., Aubry, M. C., Barrios, R. J., Beasley, M. B. and Yi, E. S. (2017). Diagnosis of acute cellular rejection and antibody-mediated rejection on lung transplant biopsies: a perspective from members of the pulmonary pathology society. Archives of Pathology & Laboratory Medicine, vol. 141, no. 3, pp. 437–444. https://doi.org/10.5858/arpa.2016-0459-sa 

Saldanha, I. J., Akinyede, O. and Robinson, K. A. 2018. Immunosuppressive drug therapy for preventing rejection following lung transplantation in cystic fibrosis. The Cochrane Database of Systematic Reviews, vol. 6, no. 6, pp. 1-16. https://doi.org/10.1002/14651858.CD009421.pub4

Vollmers, C., De Vlaminck, I., Valantine, H. A., Penland, L., Luikart, H., Strehl, C. and Quake, S. R. 2015. Monitoring pharmacologically induced immunosuppression by immune repertoire sequencing to detect acute allograft rejection in heart transplant patients: A proof-of-concept diagnostic accuracy study. PLOS Medicine, vol. 12, no. 10, pp.1-17. https://doi.org/10.1371/journal.pmed.1001890 

Claeys, E. and Vermeire, K. 2019. Immunosuppressive drugs in organ transplantation to prevent allograft rejection: Mode of action and side effects. Journal of Immunological Sciences, vol. 3, no. 4, pp. 14-21

Machado, F. P., Vicari, A. R., Spuldaro, F., Castro Filho, J. and Manfro, R. C. 2018. Polyclonal anti T-lymphocyte antibody therapy monitoring in kidney transplant recipients: comparison of CD3+ T cell and total lymphocyte counts. Einstein (Sao Paulo, Brazil), vol. 16, no. 4, pp. 1-7. https://doi.org/10.31744/einstein_journal/2018AO4278

Kühne, L., Jung, B., Poth, H., Schuster, A., Wurm, S., Ruemmele, P. and Bergler, T. 2017. Renal allograft rejection, lymphocyte infiltration, and de novo donor-specific antibodies in a novel model of non-adherence to immunosuppressive therapy. BMC Immunology, vol. 18, no. 1, pp. 1-14. https://doi.org/10.1186/s12865-017-0236-6 

Banach, D. B., Seville, M. and Kusne, S. 2016. Infection prevention and control issues after solid organ transplantation. Transplant Infections: Fourth Edition, pp. 843–867. https://doi.org/10.1007/978-3-319-28797-3_46

Mohamed, S. A. and Mostafa, H. A.-A. 2018. The effects of educational intervention on self-care behavior and expected clinical outcome in patient undergoing liver transplantation. Journal of Nursing Education and Practice, vol. 8, no. 9, pp. 100-102. https://doi.org/10.5430/jnep.v8n9p102 

Mathes, T., Großpietsch, K., Neugebauer, E. A. M. and Pieper, D. 2017. Interventions to increase adherence in patients taking immunosuppressive drugs after kidney transplantation: A systematic review of controlled trials. Systematic Reviews, vol. 6, no. 236, pp. 1-14. https://doi.org/10.1186/s13643-017-0633-1 

Myaskovsky, L., Jesse, M. T., Kuntz, K., Leino, A. D., Peipert, J. D., Russell, C. L., Spivey, C. A., Sulejmani, N. and Dew, M. A. 2018. Report from the American society of transplantation psychosocial community of practice adherence task force: Real-world options for promoting adherence in adult recipients. Clinical Transplantation, vol. 32, no. 9, pp. 1-19. https://doi.org/10.1111/ctr.13353

Hunt, H. F., Rodrigue, J. R., Dew, M. A., Schaffer, R. L., Henderson, M. L., Bloom, R., Kacani, P., Shim, P., Bolton, L., Sanchez, W. and Lentine, K. L. 2018. Strategies for increasing knowledge, communication, and access to living donor transplantation: An evidence review to inform patient education. Current Transplantation Reports, vol. 5, no. 1, pp. 27–44. https://doi.org/10.1007/s40472-018-0181-1

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