{"id":37031,"date":"2026-06-11T20:43:11","date_gmt":"2026-06-11T15:13:11","guid":{"rendered":"https:\/\/atsixty.com\/?p=37031"},"modified":"2026-06-11T20:43:49","modified_gmt":"2026-06-11T15:13:49","slug":"dialysis-transplantation-modalities-complications-rejection","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/neet-pg\/dialysis-transplantation-modalities-complications-rejection\/","title":{"rendered":"Dialysis &amp; Transplantation: Modalities, Complications &amp; Rejection"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Dialysis &amp; Transplantation<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#nep06 *,#nep06 *::before,#nep06 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font-family=\"Georgia,serif\" font-weight=\"bold\">Renal Transplant Rejection \u2014 Types &amp; Features<\/text>\n      <!-- Headers -->\n      <rect x=\"10\"  y=\"22\" width=\"100\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <rect x=\"114\" y=\"22\" width=\"100\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <rect x=\"218\" y=\"22\" width=\"105\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <rect x=\"327\" y=\"22\" width=\"100\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <rect x=\"431\" y=\"22\" width=\"100\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <text x=\"60\"  y=\"34\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Type<\/text>\n      <text x=\"164\" y=\"34\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Timing<\/text>\n      <text x=\"270\" y=\"34\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Mechanism<\/text>\n      <text x=\"377\" y=\"34\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Histology<\/text>\n      <text x=\"481\" y=\"34\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Treatment<\/text>\n      <!-- Hyperacute -->\n      <rect x=\"10\"  y=\"42\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <rect x=\"114\" y=\"42\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fdf5f5\"\/>\n      <rect x=\"218\" y=\"42\" width=\"105\" height=\"28\" rx=\"2\" fill=\"#fdf5f5\"\/>\n      <rect x=\"327\" y=\"42\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fdf5f5\"\/>\n      <rect x=\"431\" y=\"42\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fdf5f5\"\/>\n      <text x=\"60\"  y=\"53\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Hyperacute<\/text>\n      <text x=\"164\" y=\"53\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Minutes\u2013hours<\/text>\n      <text x=\"164\" y=\"63\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">on table<\/text>\n      <text x=\"270\" y=\"53\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Pre-formed anti-donor<\/text>\n      <text x=\"270\" y=\"63\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">HLA antibodies (AMR)<\/text>\n      <text x=\"377\" y=\"53\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Thrombosis, necrosis<\/text>\n      <text x=\"377\" y=\"63\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">fibrin thrombi<\/text>\n      <text x=\"481\" y=\"53\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">Irreversible;<\/text>\n      <text x=\"481\" y=\"63\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">graft removal<\/text>\n      <!-- Acute cellular -->\n      <rect x=\"10\"  y=\"72\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fff5e0\"\/>\n      <rect x=\"114\" y=\"72\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fffaf0\"\/>\n      <rect x=\"218\" y=\"72\" width=\"105\" height=\"28\" rx=\"2\" fill=\"#fffaf0\"\/>\n      <rect x=\"327\" y=\"72\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fffaf0\"\/>\n      <rect x=\"431\" y=\"72\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#fffaf0\"\/>\n      <text x=\"60\"  y=\"82\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Acute Cellular<\/text>\n      <text x=\"60\"  y=\"92\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"7\"   font-family=\"Georgia,serif\">(most common)<\/text>\n      <text x=\"164\" y=\"82\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Days\u2013months<\/text>\n      <text x=\"164\" y=\"92\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">(peak wk 1\u20133)<\/text>\n      <text x=\"270\" y=\"82\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">T-cell mediated;<\/text>\n      <text x=\"270\" y=\"92\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">CD8+ cytotoxic<\/text>\n      <text x=\"377\" y=\"82\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Tubulitis,<\/text>\n      <text x=\"377\" y=\"92\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">interstitial infiltrate<\/text>\n      <text x=\"481\" y=\"82\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">Pulse IV steroids;<\/text>\n      <text x=\"481\" y=\"92\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7\" font-family=\"Georgia,serif\">reversible<\/text>\n      <!-- Chronic -->\n      <rect x=\"10\"  y=\"102\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#d4e8f4\"\/>\n      <rect x=\"114\" y=\"102\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <rect x=\"218\" y=\"102\" width=\"105\" height=\"28\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <rect x=\"327\" y=\"102\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <rect x=\"431\" y=\"102\" width=\"100\" height=\"28\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <text x=\"60\"  y=\"112\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Chronic<\/text>\n      <text x=\"60\"  y=\"122\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7\"   font-family=\"Georgia,serif\">Alloimmune<\/text>\n      <text x=\"164\" y=\"112\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Months\u2013years<\/text>\n      <text x=\"270\" y=\"112\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Both T-cell &amp;<\/text>\n      <text x=\"270\" y=\"122\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">antibody mediated<\/text>\n      <text x=\"377\" y=\"112\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Fibrosis, intimal<\/text>\n      <text x=\"377\" y=\"122\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">hyperplasia, atrophy<\/text>\n      <text x=\"481\" y=\"112\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"7\" font-family=\"Georgia,serif\">Optimise IS;<\/text>\n      <text x=\"481\" y=\"122\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"7\" font-family=\"Georgia,serif\">no reversal<\/text>\n      <!-- Footer -->\n      <text x=\"270\" y=\"148\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7.5\" font-family=\"Georgia,serif\">Hyperacute prevented by <strong>crossmatch testing<\/strong> pre-transplant &nbsp;|&nbsp; ABO compatibility mandatory<\/text>\n      <text x=\"270\" y=\"160\" text-anchor=\"middle\" fill=\"#7A9BAD\" font-size=\"7\"   font-family=\"Georgia,serif\" font-style=\"italic\">Standard immunosuppression: tacrolimus + MMF + prednisolone (triple therapy)<\/text>\n    <\/svg>\n    <figcaption>\n      Acute cellular rejection is the most common type and the most treatable \u2014 pulse IV methylprednisolone reverses it in most cases. Hyperacute rejection is prevented by pre-transplant crossmatch; it is irreversible. Chronic allograft nephropathy is the leading cause of late graft loss.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"nep06\">\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds \u00b7 Nephrology Series \u00b7 Round 06<\/div>\n    <div class=\"mr-title\">Dialysis &amp; Transplantation<br><em>Modalities, Complications &amp; Rejection<\/em><\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Read carefully &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"nep06-sentinel\"><\/div>\n  <div class=\"mr-progress\" id=\"nep06-progress\">\n    <div class=\"mr-prog-inner\"><div class=\"mr-pips\" id=\"nep06-pips\"><\/div><\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"nep06-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"nep06-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"nep06-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"nep06-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"nep06-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"nep06-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"nep06-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"nep06-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"nep06-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"nep06-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"nep06-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n\n<script>\n(function(){\n  'use strict';\n  var NS='nep06',TOTAL=5,MAX=20,LTRS=['A','B','C','D'];\n\n  var QS=[\n    {\n      id:1,\n      tag:'Dialysis &mdash; HD vs PD: Choosing the Modality',\n      stem:'A <strong>38-year-old woman<\/strong> with ESRD from lupus nephritis is counselled about renal replacement therapy. She lives far from a dialysis centre, works from home, and has a <strong>well-healed abdominal wall with no prior abdominal surgeries<\/strong>. Her residual renal function is modest. She strongly values autonomy and flexibility. Which modality and access is most aligned with her circumstances, and what is its primary physiological advantage over haemodialysis?',\n      correct:'Peritoneal dialysis (PD) via a Tenckhoff catheter; uses the peritoneum as a continuous semi-permeable membrane, preserving residual renal function better than HD',\n      opts:[\n        'Peritoneal dialysis (PD) via a Tenckhoff catheter; uses the peritoneum as a continuous semi-permeable membrane, preserving residual renal function better than HD',\n        'Haemodialysis via an AV fistula; more efficient solute clearance makes it the default choice regardless of lifestyle',\n        'Haemodialysis via a tunnelled central venous catheter; preferred in all women of childbearing age',\n        'Conservative management only; lupus nephritis patients are not candidates for transplantation'\n      ],\n      exp:'<strong>Peritoneal dialysis (PD)<\/strong> is performed at home, typically either as CAPD (4 exchanges\/day by hand) or APD (automated overnight machine cycling). It suits patients who are remote from a dialysis centre, value independence, and have intact peritoneum. Compared to HD: <strong>PD better preserves residual renal function (RRF)<\/strong> \u2014 the haemodynamic stability of continuous dialysis avoids the episodic hypotension of HD that accelerates RRF loss. RRF correlates with better survival and quality of life. PD is <em>contraindicated<\/em> with prior extensive abdominal surgery\/adhesions, abdominal wall herniae, or inflammatory bowel disease. A <strong>Tenckhoff catheter<\/strong> is the standard PD access. Absolute contraindications to PD include obliterated peritoneal cavity. HD remains superior for <em>solute clearance efficiency per session<\/em> (KT\/V target &ge;1.2 per session, three times weekly) but at the cost of haemodynamic stress.',\n      imgId:null\n    },\n    {\n      id:2,\n      tag:'Dialysis &mdash; Haemodialysis Complications',\n      stem:'A <strong>62-year-old man<\/strong> on thrice-weekly haemodialysis develops <strong>hypotension<\/strong> 90 minutes into a session. His pre-dialysis weight was 4 kg above his dry weight. He becomes pale, nauseated, and his BP drops from 148\/88 to 88\/60 mmHg. Which is the <em>most common<\/em> cause of intra-dialytic hypotension and the correct immediate management?',\n      correct:'Excessive ultrafiltration rate relative to plasma refilling; stop UF, place supine, give IV saline bolus or hypertonic saline',\n      opts:[\n        'Excessive ultrafiltration rate relative to plasma refilling; stop UF, place supine, give IV saline bolus or hypertonic saline',\n        'Dialyser reaction (anaphylaxis); stop HD immediately, administer IV adrenaline',\n        'Air embolism from circuit disconnection; clamp lines, place in left lateral Trendelenburg',\n        'Cardiac tamponade from uraemic pericarditis; emergency pericardiocentesis'\n      ],\n      exp:'<strong>Intra-dialytic hypotension (IDH)<\/strong> is the commonest acute HD complication, occurring in ~20\u201330% of sessions. The predominant mechanism: <strong>ultrafiltration (UF) rate exceeds the rate at which plasma refilling from the interstitium can compensate<\/strong>, causing intravascular volume depletion. Precipitating factors: large interdialytic weight gain requiring aggressive UF, eating during dialysis (splanchnic vasodilation), antihypertensives taken pre-session, autonomic neuropathy (diabetics). <strong>Immediate management<\/strong>: (1) reduce or stop UF, (2) Trendelenburg positioning, (3) IV normal saline 100\u2013200 mL bolus or hypertonic saline (3%) or albumin. Prevention: sodium profiling, cooled dialysate (35\u00b0C), UF rate limits (&lt;13 mL\/kg\/h), withhold antihypertensives on dialysis days. Dialyser reactions are rare and present with urticaria\/bronchospasm. Air embolism causes sudden chest pain and coughing with a mill-wheel murmur.',\n      imgId:null\n    },\n    {\n      id:3,\n      tag:'Dialysis &mdash; Peritoneal Dialysis Complications',\n      stem:'A <strong>45-year-old woman<\/strong> on CAPD for 2 years develops <strong>cloudy effluent<\/strong>, diffuse abdominal pain, and fever (38.6\u00b0C). PD effluent cell count shows <strong>450 WBC\/mm&sup3;<\/strong> with 85% neutrophils. Gram stain is pending. What is the diagnosis and the empirical antibiotic regimen?',\n      correct:'PD peritonitis; empirical intraperitoneal vancomycin (Gram-positive cover) + ceftazidime or aminoglycoside (Gram-negative cover)',\n      opts:[\n        'PD peritonitis; empirical intraperitoneal vancomycin (Gram-positive cover) + ceftazidime or aminoglycoside (Gram-negative cover)',\n        'Chemical peritonitis from hyperosmolar dialysate; stop PD and start IV antibiotics empirically',\n        'Exit-site infection only; oral antibiotics and local care are sufficient without IP treatment',\n        'Haemoperitoneum; the cell count confirms bleeding, not infection'\n      ],\n      exp:'<strong>PD peritonitis<\/strong> is diagnosed when effluent WBC &gt;100\/mm&sup3; with &gt;50% neutrophils \u2014 this patient has 450 WBC, overwhelming the threshold. Clinical features: cloudy bag, abdominal pain, fever. Commonest organisms: coagulase-negative <em>Staphylococcus<\/em> (touch contamination), <em>S. aureus<\/em>, Gram-negatives. <strong>Empirical treatment<\/strong>: <strong>intraperitoneal (IP) antibiotics<\/strong> \u2014 continuous (in every exchange) or intermittent. IP vancomycin covers Gram-positives (including MRSA); IP ceftazidime or gentamicin covers Gram-negatives. Switch guided by culture results. Duration: 2 weeks for Gram-positive cocci, 3 weeks for Gram-negatives, 6 weeks for fungal (plus catheter removal). <strong>Catheter removal indications<\/strong>: fungal peritonitis, refractory\/relapsing peritonitis, tunnel infection with peritonitis, faecal peritonitis. This is the leading infectious cause of PD technique failure and transition to HD.',\n      imgId:null\n    },\n    {\n      id:4,\n      tag:'Transplant &mdash; Rejection Recognition',\n      stem:'A <strong>30-year-old man<\/strong> received a deceased-donor kidney transplant <strong>10 days ago<\/strong>. He presents with oliguria, rising creatinine (from 1.4 to 3.2 mg\/dL over 3 days), fever, and graft tenderness. Ultrasound shows increased graft size with reduced diastolic flow. Crossmatch was negative pre-transplant. What is the most likely diagnosis and treatment?',\n      correct:'Acute cellular rejection; pulse IV methylprednisolone 500 mg daily for 3 days',\n      opts:[\n        'Acute cellular rejection; pulse IV methylprednisolone 500 mg daily for 3 days',\n        'Hyperacute rejection; graft nephrectomy is mandatory',\n        'Calcineurin inhibitor (tacrolimus) nephrotoxicity; reduce tacrolimus dose',\n        'Urinary tract obstruction; urgent nephrostomy tube insertion'\n      ],\n      exp:'<strong>Acute cellular rejection (ACR)<\/strong> peaks at 1\u20133 weeks post-transplant and is the commonest form of acute rejection. Features: rising creatinine, oliguria, graft swelling and tenderness, low-grade fever. The <em>negative crossmatch<\/em> excludes hyperacute rejection (pre-formed antibodies). Tacrolimus toxicity causes creatinine rise but without fever or graft tenderness, and tacrolimus levels would be elevated. Obstruction would show hydronephrosis on ultrasound. Biopsy confirms ACR: <strong>tubulitis + interstitial lymphocytic infiltrate (Banff criteria)<\/strong>. <strong>Treatment<\/strong>: <strong>pulse IV methylprednisolone 500 mg daily &times; 3 days<\/strong> \u2014 reverses ACR in ~80% of cases. Steroid-resistant ACR: anti-thymocyte globulin (ATG). The standard maintenance immunosuppression triple therapy is tacrolimus + MMF + prednisolone.',\n      imgId:'nep06-img4'\n    },\n    {\n      id:5,\n      tag:'Transplant &mdash; Post-Transplant Complications',\n      stem:'A <strong>42-year-old woman<\/strong>, 18 months post living-donor renal transplant on tacrolimus, MMF, and prednisolone, presents with a painless <strong>cervical lymph node swelling<\/strong>. She is EBV seropositive. CT shows multiple lymph node masses. Biopsy shows a <strong>B-cell lymphoproliferative lesion<\/strong>. What is the diagnosis and the first-line treatment principle?',\n      correct:'Post-transplant lymphoproliferative disorder (PTLD); first step is reduction of immunosuppression',\n      opts:[\n        'Post-transplant lymphoproliferative disorder (PTLD); first step is reduction of immunosuppression',\n        'Acute graft-versus-host disease; stop MMF immediately and increase steroids',\n        'CMV lymphadenitis; treat with IV ganciclovir for 3 weeks',\n        'Tacrolimus-induced lymphoma; switch to cyclosporine and start R-CHOP chemotherapy immediately'\n      ],\n      exp:'<strong>Post-transplant lymphoproliferative disorder (PTLD)<\/strong> is a spectrum of lymphoid proliferations driven by <strong>EBV reactivation<\/strong> in the setting of T-cell immunosuppression. Incidence: ~1\u20133% of solid organ transplant recipients. EBV-infected B-cells proliferate unchecked because EBV-specific cytotoxic T-cells are suppressed by calcineurin inhibitors. Clinical: lymphadenopathy, B-symptoms, extranodal masses (GI, CNS). <strong>First-line treatment: reduction of immunosuppression (RIS)<\/strong> \u2014 decrease or stop MMF first (least critical for graft survival), then reduce calcineurin inhibitor. This restores some anti-EBV T-cell immunity and causes regression in ~30\u201350% of low-grade PTLD. For CD20+ lesions not responding to RIS: <strong>rituximab<\/strong> (anti-CD20). Chemotherapy (R-CHOP) reserved for aggressive\/high-grade PTLD. PTLD is one of the most feared long-term complications of transplantation, illustrating the central trade-off between immunosuppression sufficient to prevent rejection and the oncological and infective risks it carries.',\n      imgId:null\n    }\n  ];\n\n  var answers={},answered=0,shuffled={},done=false;\n  function byId(id){return document.getElementById(id);}\n  function gid(s){return byId(NS+'-'+s);}\n  function shuffleArr(arr){var a=arr.slice(),i,j,tmp;for(i=a.length-1;i>0;i--){j=Math.floor(Math.random()*(i+1));tmp=a[i];a[i]=a[j];a[j]=tmp;}return a;}\n  function countVal(val){var k,n=0;for(k in answers){if(answers.hasOwnProperty(k)&&answers[k]===val)n++;}return n;}\n  function buildPips(){\n    var cont=gid('pips'),i,q,wLine,wPip,line,pip;cont.innerHTML='';\n    for(i=0;i<QS.length;i++){\n      q=QS[i];\n      if(i>0){wLine=document.createElement('div');wLine.className='mr-pip-wrap';line=document.createElement('div');line.className='mr-pip-line';line.id=NS+'-pl'+q.id;wLine.appendChild(line);cont.appendChild(wLine);}\n      wPip=document.createElement('div');wPip.className='mr-pip-wrap';pip=document.createElement('div');pip.className='mr-pip';pip.id=NS+'-pip'+q.id;pip.textContent=String(q.id);wPip.appendChild(pip);cont.appendChild(wPip);\n    }\n  }\n  function build(){\n    var cont,i,q,opts,card,top,numDiv,meta,tag,stem,rule,optsDiv,expDiv,lbl,txt,imgDiv,imgSrc,j,optEl,ltrSpan,txtSpan;\n    cont=gid('cases');cont.innerHTML='';answers={};answered=0;shuffled={};done=false;gid('score').style.display='none';buildPips();\n    for(i=0;i<QS.length;i++){\n      q=QS[i];opts=shuffleArr(q.opts);shuffled[q.id]=opts;\n      card=document.createElement('div');card.className='mr-case';\n      top=document.createElement('div');top.className='mr-case-top';\n      numDiv=document.createElement('div');numDiv.className='mr-num';numDiv.textContent=q.id<10?'0'+q.id:String(q.id);\n      meta=document.createElement('div');meta.className='mr-meta';\n      tag=document.createElement('div');tag.className='mr-tag';tag.innerHTML=q.tag;\n      stem=document.createElement('div');stem.className='mr-stem';stem.innerHTML=q.stem;\n      meta.appendChild(tag);meta.appendChild(stem);top.appendChild(numDiv);top.appendChild(meta);card.appendChild(top);\n      rule=document.createElement('div');rule.className='mr-rule';card.appendChild(rule);\n      optsDiv=document.createElement('div');optsDiv.className='mr-opts';\n      for(j=0;j<opts.length;j++){\n        optEl=document.createElement('div');optEl.className='mr-opt';optEl.id=NS+'-o'+q.id+'-'+j;optEl.setAttribute('role','button');optEl.setAttribute('tabindex','0');\n        ltrSpan=document.createElement('span');ltrSpan.className='mr-ltr';ltrSpan.textContent=LTRS[j];\n        txtSpan=document.createElement('span');txtSpan.className='mr-opt-text';txtSpan.innerHTML=opts[j];\n        optEl.appendChild(ltrSpan);optEl.appendChild(txtSpan);optsDiv.appendChild(optEl);\n        (function(qid,oi){optEl.addEventListener('click',function(){pick(qid,oi);});}(q.id,j));\n      }\n      card.appendChild(optsDiv);\n      expDiv=document.createElement('div');expDiv.className='mr-exp';expDiv.id=NS+'-exp'+q.id;\n      lbl=document.createElement('div');lbl.className='mr-exp-lbl';lbl.textContent='Debrief';\n      txt=document.createElement('div');txt.className='mr-exp-text';txt.innerHTML=q.exp;\n      expDiv.appendChild(lbl);expDiv.appendChild(txt);\n      if(q.imgId){imgSrc=byId(q.imgId);if(imgSrc){imgDiv=document.createElement('div');imgDiv.innerHTML=imgSrc.innerHTML;expDiv.appendChild(imgDiv);}}\n      card.appendChild(expDiv);cont.appendChild(card);\n    }\n  }\n  function pick(qid,oi){\n    var q,opts,i,el,correct;\n    if(answers[qid]!==undefined||done)return;\n    q=null;for(i=0;i<QS.length;i++){if(QS[i].id===qid){q=QS[i];break;}}if(!q)return;\n    opts=shuffled[qid];correct=(opts[oi]===q.correct);answers[qid]=correct?'c':'w';answered++;\n    for(i=0;i<opts.length;i++){\n      el=byId(NS+'-o'+qid+'-'+i);\n      if(opts[i]===q.correct){el.className='mr-opt correct locked';}\n      else if(i===oi){el.className='mr-opt wrong locked';}\n      else{el.className='mr-opt dimmed locked';}\n    }\n    byId(NS+'-exp'+qid).style.display='block';\n    byId(NS+'-pip'+qid).className='mr-pip '+(correct?'correct':'wrong');\n    if(qid>1){var pl=gid('pl'+qid);if(pl)pl.className='mr-pip-line done';}\n  }\n  function showScore(){\n    var c,w,s,net,pct,disp,verdicts,vi,sc;\n    if(done)return;done=true;\n    c=countVal('c');w=countVal('w');s=TOTAL-answered;\n    net=(c*4)-w;pct=Math.max(0,Math.round((net\/MAX)*100));disp=Math.min(100,Math.max(0,pct));\n    gid('ring').style.background='conic-gradient(#2A5470 '+disp+'%, #D8E6EE 0%)';\n    gid('pct').textContent=pct+'%';gid('net').textContent='Net Score: '+net+' \/ '+MAX;\n    verdicts=[[5,'Perfect round. 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Transplantation Renal Transplant Rejection \u2014 Types &amp; Features Type Timing Mechanism Histology Treatment Hyperacute Minutes\u2013hours on table Pre-formed anti-donor HLA antibodies (AMR) Thrombosis, necrosis fibrin thrombi Irreversible; graft removal Acute Cellular (most common) Days\u2013months (peak wk 1\u20133) T-cell mediated; CD8+ cytotoxic Tubulitis, interstitial infiltrate Pulse IV steroids; reversible Chronic Alloimmune&hellip;&nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[24,80],"tags":[],"class_list":["post-37031","post","type-post","status-publish","format-standard","hentry","category-neet-pg","category-nephrology"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Dialysis &amp; 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