How do you approach chronic T cell mediated rejection when patient is intolerant to steroids?  

I would really want to know in what way the patient is intolerant to steroids. Depending on the degree of activity, I would also consider thymoglobulin and maximize the mycophenolate. CNI dosing would depend on the degree of chronicity, but in general, I would aim for a tacrolimus level of 6-8 ng/ml...

I would consider anti-thymoglobulin antibody if patient is robust and eGFR is still preserved (>30ml/min) in this instance and optimize immunosuppression as much as tolerated.  A follow up biopsy following treatment may be helpful together with the use of a biomarker to gauge response.

In the case of chronic active T cell mediated rejection, will maximize oral IS as much as tolerated. Will give thymo in selected cases with limited IFTA and, preserved GFR. HMW