A Case of Desensitization, Transplantation, and Allograft Dysfunction

A 41-yr-old Asian-American woman presented for evaluation for a second kidney transplant in 2005. She had a potential living kidney donor, a sister. The patient had developed end-stage renal disease from IgA glomerulonephritis. This was first diagnosed in 1989; in 1991, she underwent a preemptive living donor transplant in another hospital. The donor was another sister and the allograft was a 2-haplotype match. Despite this, her early post-transplant course was complicated by severe acute rejection (further information on this was not available). She also developed mitral valve endocarditis with septic embolization to the brain and, in addition to prolonged antimicrobial therapy, required craniotomy and insertion of a prosthetic mitral valve. Fortunately, she made an excellent recovery. She was later diagnosed as having chronic allograft nephropathy and resumed peritoneal dialysis in 2005 and stopped immunosuppression at that time. She had received blood transfusions in the early period after her first transplant but had had no pregnancies. The only other medical history was hypertension. Her functional status was excellent. Examination was unremarkable apart from the prosthetic mitral valve click.Investigations showed the potential donor was a 1–2–2 human leukocyte antigen (HLA) mismatch with the potential recipient. The latter was blood group ABO-AB and had a panel reactive antibody (PRA) of 0% against class I HLA by the complement-dependent cytotoxicity (CDC) assay. However, by the more sensitive FlowPRA assay, the PRA against class I antigens was 35% and against class II antigens was 98%. The crossmatch against T cells of the potential donor was negative by the CDC (antihuman globulin) method but was strongly positive against B cells by the CDC (modified Amos) method: positive out to a 1:256 dilution The patient was diagnosed as being very highly sensitized to class II HLA antigens of the donor and informed that the transplant would …