The clinical features of AHR consist of severe and acute (days) graft dysfunction that is not responsive to steroids or usually antilymphocytes antibodies and with a higher rate of graft loss than cellular rejection. It can arise any time after transplant. The risk factors for AHR include elevated panel reactive antibody (PRA), prior transplant, and historically positive cross-match, all associated with prior sensitization (35-38). Patients who reduce immunosuppression late after transplant, either due to noncompli-ance or nonabsorption, can manifest AHR.

Figure 20.5. Humoral rejection, type I. Acute tubular injury is evident, without neutrophils in capillaries. The C4d stain was positive.
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