The incidence of acute Rejection of the kidney allograft in the world has been around 15% during the period between 2001 and 2003. It is clinically defined as an elevation in the level of serum creatinine by more than 0.3 mg/dL and is diagnosed by kidney biopsy. On pathologic examination, the interstitium of the allograft is diffusely edematous and infiltrated by CD4 and CD8 lymphocytes. Tubulitis occurs when the lymphocytes and monocytes extend into the walls and lumina of the tubules. Presence of leukocytes determines infection or antibody-mediated Rejection. Typically C4d staining is negative. Other causes of acute allograft dysfunction included prerenal factors, interstitial nephritis, infection, acute tubular necrosis, toxicity by drugs, and obstruction in the urinary tract.The primary diagnostic assessments include history, especially adherence to immunosuppressive therapy, physical examination, blood and urine laboratory tests, measurement of the serum levels of the drugs, and ultrasonography. Diagnosis of acute cellular Rejection depends on biopsy, CD20 staining for refractory cases, negative C4d staining, presence of markers of activating lymphocyte, and proteomic study. Treatment of acute cellular Rejection in kidney transplant recipients include pulse steroid for the first Rejection episode. It can be repeated for recurrent or resistant Rejection. Thymoglobulin and OKT3 are used as the second line of treatment if graft function is deteriorating. Changing the protocol from cyclosporine to tacrolimus or adding mycophenolate mofetil or sirolimus might be effective. Prognosis depends on number of Rejection episodes, the use of potent drugs, time of Rejection from transplantation, and response to treatment.

Purpose: To describe the clinical features, management, and visual outcome in a case of stromal Rejection with a rare and unusual presentation after deep anterior lamellar keratoplasty (DALK).Case report: A 25-year-old healthy man with advanced keratoconus underwent DALK using the standard big bubble technique in his right eye. Five months after surgery, the patient involved in red eye, decreased vision, acute epithelial edema, acute and diffuse stromal edema, fine diffuse keratic precipitates (KPs) in the graft location and AC (anterior chamber) inflammation with cells and flair without any vascularization in the graft and recipient bed, and any infiltration or loosening of the sutures. Management with topical and systemic steroids, and topical antibiotic lead to complete resolution of stromal edema, KPs and AC inflammation. Nine months after the first episode, the patient was referred due to the same clinical presentation and similar findings on examination. Recurrence was treated successfully with the same prior medications and clear graft was achieved.Conclusion: Although there is no endothelial immune reaction after DALK for keratoconus, stromal graft Rejection after DALK can be presented with the same features as endothelial graft Rejection and should be differentiated from herpes simplex virus (HSV) keratouveitis.

Chronic antibody-mediated Rejection among kidney transplant recipients is a major unresolved problem which is covered in this review article which included different lines of its management.