Naming rejection, crossing barriers, and spending drugs frugally

(A) Cross both barriers together: alternate-day plasma exchange with low-dose immune globulin until donor antibody falls and isoagglutinins pass — with no hyperacute rejection, both barriers crossed at once, and the single antibody rejection reversed by re-treatment.^[11] Respect the antibody after: donor antibody can mean rejection without C4d or histology and can precede the stains — so dysfunction with antibody is treated despite a negative biopsy.^[12]

(B) Minimise calcineurin where trials allow: low-dose tacrolimus triple led 1,645 recipients on filtration, rejection and survival — yet withdrawal at six months on a depletional backbone improves function and chronic histology without moving survival or rejection.^[4][24] The mTOR route preserves kidneys with survival tied — priced in lipids, diabetes and wounds — so tailor minimisation to the patient's dominant toxicity.^[9]

(C) Give 200 days of cover for the high-risk pair as standard — then spare the marrow where it matters: letermovir matches valganciclovir on disease at 10.4 against 11.8% with white-cell toxicity at 26 against 64% and fewer stopped courses.^[14]