title: T-cell-mediated rejection of the kidney in the era of donor-specific antibodies: diagnostic challenges and clinical significance.
abstract: OBJECTIVE
  Burgeoning literature on antibody-mediated rejection (ABMR) has led to a perception that T-cell-mediated rejection (TCMR) is no longer a significant problem. This premise needs to be carefully appraised.
  
  
  RESULTS
  A review of the literature indicates that TCMR remains an independent-risk factor for graft loss. Importantly, it can occur as a sensitizing event that triggers ABMR, and adversely affects its outcome. Moreover, T cells are regularly present in lesions used to diagnose ABMR, and these lesions can also develop in the absence of donor-specific antibodies (DSA). Conversely, patients with DSA are at risk for mixed ABMR-TCMR, which is quite common in many studies, and may require a combined anti-T-cell and anti-B-cell strategy for the best outcome.
  
  
  CONCLUSIONS
  T-cell-based clinical monitoring and therapy is still relevant for prophylaxis of both cellular and humoral rejection, treatment of steroid refractory TCMR, which occurs in up to 20% of patients, and optimization of clinical outcome in mixed TCMR-ABMR, which is more frequently encountered than generally appreciated, and still associated with unacceptably high rates of graft loss.
authors.affiliation: Division of Transplantation Pathology, Department of Pathology, The Thomas E Starzl Transplantation Institute, University of Pittsburgh, University of Pittsburgh, Pennsylvania, USA.
authors.forename: Parmjeet
authors.initials: P
authors.lastname: Randhawa
mesh_terms: D000906:Antibodies / Q000276:immunology*; D006084:Graft Rejection / Q000276:immunology*; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects*; D013601:T-Lymphocytes / Q000276:immunology*; D014019:Tissue Donors
chemical_list: D000906:Antibodies