Renal Allograft Rejection: Noninvasive Ultrasound- and MRI-Based Diagnostics

Abstract

To date, allogeneic kidney transplantation remains the best available therapeutic option for patients with end-stage renal disease regarding overall survival and quality of life. Despite the advancements in immunosuppressive drugs and protocols, episodes of acute allograft rejection, a sterile inflammatory process, continue to endanger allograft survival. Since effective treatment for acute rejection episodes is available, instant diagnosis of this potentially reversible graft injury is imperative. Although histological examination by invasive core needle biopsy of the graft remains the gold standard for the diagnosis of ongoing rejection, it is always associated with the risk of causing substantial graft injury as a result of the biopsy procedure itself. At the same time, biopsies are not immediately feasible for a considerable number of patients taking anticoagulants due to the high risk of complications such as bleeding and uneven distribution of pathological changes within the graft. This can result in the wrong diagnosis due to the small size of the tissue sample taken. Therefore, there is a need for a tool that overcomes these problems by being noninvasive and capable of assessing the whole organ at the same time for specific and fast detection of acute allograft rejection. In this article, we review current state-of-the-art approaches for noninvasive diagnostics of acute renal transplant inflammation, i.e., rejection. We especially focus on nonradiation-based methods using magnetic resonance imaging (MRI) and ultrasound.

Figure 1

Representative ultrasound images of an allogeneic kidney transplantation in a rat (atx, allograft) (a): its native control kidney (native)(b) 4 days after transplantation before (pre-CM), 15 minutes after tail vein injection of microbubbles labeled with an antibody targeted against CD3 positive T cells (post-CM). CM: contrast media/microbubbles conjugated with anti-CD3 antibody [28].

Figure 2

Representative in vivo ASL perfusion (a) and glucoCEST MTR_asym (b) maps of the renal cortex and medulla of an allogeneic transplantation in a rat on day 4 posttransplantation, showing the renal allograft undergoing an acute cellular rejection on the right side (L) and the healthy right contralateral kidney on the left side (R).