A 57-year-old woman with autosomal dominant polycystic kidney disease develops end-stage renal disease and undergoes deceased-donor kidney transplantation. During the operation, the surgeon notices that the graft becomes cyanotic and mottled soon after its blood vessels are connected with those of the recipient. Blood flow to the graft ceases, and no urine is produced. Which of the following best explains the findings observed by the surgeon?

Question

A 57-year-old woman with autosomal dominant polycystic kidney disease develops end-stage renal disease and undergoes deceased-donor kidney transplantation.  During the operation, the surgeon notices that the graft becomes cyanotic and mottled soon after its blood vessels are connected with those of the recipient.  Blood flow to the graft ceases, and no urine is produced.  Which of the following best explains the findings observed by the surgeon?

Quizplus · Accepted Answer

11ec160b_37c2_b0a1_9249_856d944eaf5d_MD0001_00 This patient is experiencing hyperacute rejection of a renal transplant. Hyperacute rejection is an antibody-mediated reaction (ie, type II hypersensitivity) caused by preformed IgG antibodies in the recipient that are directed against donor antigens. These are commonly anti-HLA antibodies (eg, formed during prior blood transfusion or pregnancy) or ABO blood group antibodies. Hyperacute rejection is usually diagnosed in the operating room when the kidney becomes cyanotic and mottled after anastomosis of the donor and recipient blood vessels. Perfusion through the transplanted organ ceases immediately due to antibody- and complement-mediated vascular injury with subsequent thrombotic occlusion. This rapidly leads to ischemic necrosis of the glomeruli and renal cortex with little to no urine output and irreversible graft loss. To minimize the risk of hyperacute rejection, donor and recipient ABO and HLA cross-matching is performed prior to renal transplantation. (Choice A) Activation of recipient T lymphocytes is the primary mechanism of acute organ transplant rejection. Recipient T cells are sensitized by donor graft antigens, leading to cell-mediated (ie, type IV hypersensitivity) rejection that typically occurs within 6 months after transplant. This type of rejection is generally reversible with increased doses of immunosuppression. (Choice C) Degranulation of mast cells and basophils occurs during a type I hypersensitivity reaction (eg, allergic response), which is not involved in organ transplant rejection. (Choice D) Graft versus host disease results from donor T lymphocytes activating against recipient antigens, leading to vasculitis and tissue damage of recipient organs (eg, skin, liver, gastrointestinal tract). (Choice E) Atherosclerotic stenosis of the transplanted renal artery can occur over time, but it would not cause acute graft ischemia with cyanosis and mottling at the time of transplant surgery. Educational objective: Hyperacute rejection is caused by preformed antibodies in the recipient that recognize and attack donor antigens (ie, type II hypersensitivity). These are often anti-ABO blood group or anti-HLA antibodies. Vascular injury and capillary thrombotic occlusion lead to rapid ischemic necrosis of the renal graft, often evidenced by gross cyanosis and mottling immediately following graft perfusion. __________ References: Root cause analysis of limitations of virtual crossmatch for kidney allocation to highly-sensitized patients. (http://www.ncbi.nlm.nih.gov/pubmed/27864154) The major histocompatibility complex in transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/22778908)

A 57-Year-Old Woman with Autosomal Dominant Polycystic Kidney Disease Develops