ZyraDoc #44 - September 14, 2026

A 38-year-old male recipient of a living-donor kidney transplant 4 months ago presents with an asymptomatic rise in serum creatinine from a baseline of 1.1 mg/dL to 2.4 mg/dL over the past week.

He admits to missing several doses of his maintenance immunosuppressive regimen (tacrolimus and mycophenolate mofetil) due to a recent change in work shifts.

Physical examination reveals mild graft tenderness over the right iliac fossa and lower extremity pitting edema, while renal Doppler ultrasound shows normal vascular flow and rules out mechanical urinary outflow obstruction.

Case Summary

Clinical Focus:

The diagnosis is Acute Renal Allograft Rejection.

Aetiology/Cause:

Acute T-cell mediated rejection (TCMR) caused by host T-lymphocyte infiltration and immune destruction of renal tubular and vascular structures.
Acute antibody-mediated rejection (ABMR) driven by donor-specific anti-HLA antibodies activating microvascular inflammation and complement pathways.
Subtherapeutic immunosuppressive drug levels secondary to patient non-adherence, drug interactions, or inadequate dosing.

Clinical Features:

Asymptomatic deterioration in renal graft function characterized by a rapid or progressive increase in serum creatinine.
Signs of volume overload including new or worsening hypertension, oliguria, and peripheral lower limb edema.
Local physical signs including palpable swelling, warmth, or tenderness directly over the renal allograft site.
Systemic signs such as low-grade fever, malaise, and flu-like symptoms (more prominent in cell-mediated rejection).

Diagnosis and Investigations:

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