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Are borderline changes real rejection? Current viewpoints.

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Borderline changes in kidney transplants are linked to worse outcomes, but treatment benefits are debated. New biomarkers may help diagnose and manage this condition, potentially avoiding biopsies.

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Area of Science:

  • Nephrology
  • Transplant Immunology
  • Pathology

Background:

  • Borderline changes in kidney allografts present diagnostic and therapeutic challenges.
  • The clinical significance and optimal management of borderline changes remain controversial.
  • Histological criteria for identifying borderline changes and predicting outcomes require further clarification.

Purpose of the Study:

  • To review recent evidence on borderline changes in kidney allografts.
  • To explore the association of borderline changes with graft outcomes and fibrosis progression.
  • To evaluate the potential of novel biomarkers for diagnosing subclinical rejection and guiding treatment.

Main Methods:

  • Review of recent scientific literature on kidney allograft borderline changes.
  • Analysis of histological findings and their correlation with clinical outcomes.
  • Evaluation of emerging noninvasive biomarkers, including gene expression, cell-free DNA, and HLA eplet mismatch.

Main Results:

  • Borderline changes (Banff ≥ t1i1) are associated with progressive fibrosis, de-novo DSA, and reduced graft survival.
  • Treatment of borderline changes may improve kidney function recovery and clinical outcomes, though spontaneous resolution occurs.
  • Noninvasive biomarkers show promise for diagnosing subclinical acute rejection (borderline changes and ≥ Banff 1A TCMR) and predicting allograft outcomes.

Conclusions:

  • Borderline changes are linked to adverse kidney allograft outcomes, but the necessity of treatment for all cases is uncertain.
  • Novel biomarkers could aid clinicians in diagnosing and treating borderline changes, potentially reducing the need for surveillance biopsies.
  • Further research is needed to validate these biomarkers and refine treatment strategies for borderline changes.