Pseudorejection and true rejection after kidney transplantation: classification and clinical significance

Urol Int. 2013;90(4):373-80. doi: 10.1159/000342965. Epub 2012 Oct 19.


Objectives: Multiple factors may result in an elevation in serum creatinine level after kidney transplantation, mimicking rejection. It is crucial to differentiate between a true rejection and other conditions inducing a 'pseudorejection', in order to avoid overtreatment, or worse, mistreatment. Our goal was to review and classify true rejections and pseudorejections and their clinical significance.

Material and methods: This was a retrospective review of articles published in the USA and Europe, from 1976 to the present. The sites from which information was retrieved included PubMed, Clinical Imaging, Histopathology, Archives of Surgery, JACS, the American Urological Association, Medline and Springer Link. The importance of the resistive index will also be emphasized.

Results: We reviewed 61 articles regarding the causes of renal graft dysfunction, which may be classified into true rejections and pseudorejections, the latter including the following 6 factors: hyperglycemia, ureteral obstruction, lymphocele, arterial stenosis, infection and recurrence of primary pathology.

Conclusions: 'Pseudorejection' has been described only once, for the first time in 1976 in the USA, and there have been no other reports since then. Multiple factors, mainly hyperglycemia, may induce a pseudorejection, presenting with an elevation of serum creatinine level and leading the clinician to an erroneous diagnosis of true rejection initially, resulting in inappropriate management.

Publication types

  • Review

MeSH terms

  • Biomarkers / blood
  • Creatinine / blood
  • Diagnostic Errors
  • Graft Rejection / blood
  • Graft Rejection / classification
  • Graft Rejection / diagnosis
  • Graft Rejection / etiology*
  • Graft Rejection / therapy
  • Humans
  • Kidney Transplantation / adverse effects*
  • Predictive Value of Tests
  • Risk Factors
  • Treatment Outcome
  • Unnecessary Procedures
  • Up-Regulation


  • Biomarkers
  • Creatinine