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A case of accelerated acute rejection after ABO‐compatible living unrelated kidney transplantation
Author(s) -
Matsuo Nanae,
Yamamoto Hiroyasu,
Kobayashi Akimitsu,
Yamamoto Izumi,
Mitome Jun,
Maruyama Yukio,
Hayakawa Hiroshi,
Miyazaki Yoichi,
Utsunomiya Yasunori,
Hosoya Tatsuo,
Yamaguchi Yutaka
Publication year - 2009
Publication title -
clinical transplantation
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.918
H-Index - 76
eISSN - 1399-0012
pISSN - 0902-0063
DOI - 10.1111/j.1399-0012.2009.01004.x
Subject(s) - medicine , transplantation , panel reactive antibody , kidney transplantation , basiliximab , plasmapheresis , urology , gastroenterology , rituximab , immunosuppression , chronic allograft nephropathy , methylprednisolone , immunology , antibody
A 59‐yr‐old Japanese woman with chronic renal failure caused by IgA nephropathy and antineutrophil cytoplasmic antibody (ANCA)‐related glomerulonephritis underwent kidney transplantation from a living unrelated spousal donor. The blood type was compatible, while the human leukocyte antigen (HLA) typing showed a 5/6 locus mismatch. She had become pregnant twice by her donor and had never received blood transfusions. Complement‐dependent cytotoxicity cross‐match, flow cytometry cross‐match (FCXM), and flow panel reactive antibody (PRA) were negative. She initially underwent one week of immunosuppression with mycophenolate mofetil (MMF) and double filtration plasmapheresis (DFPP) immediately before transplantation to reduce the risk of antibody‐mediated rejection. Induction therapy consisted of MMF, tacrolimus (TAC), methylprednisolone (MP), and basiliximab. The allograft function was excellent immediately after the operation. However, the urine output and platelet count declined rapidly on post‐operative day (POD) 3, while the serum creatinine (sCr) and lactate dehydrogenase levels rose gradually. Subsequently, we could not detect the diastolic arterial flow on Doppler sonography. We diagnosed accelerated acute rejection and treated her with plasma exchange (PEX), intravenous MP pulse therapy, and rituximab. The first episode biopsy on POD 7 revealed acute vascular rejection and acute antibody‐mediated rejection (Banff score AMR II). Her urinary excretion increased beginning on POD 13, while the sCr level decreased gradually and reached 0.9 mg/dL on POD 22. In our retrospective analysis, the LAB screen detected donor‐specific antibody (DSA). This case suggested that, for successful kidney transplantation in highly sensitized recipients, such as husband‐to‐wife spousal kidney transplantation with a history of pregnancy, we should keep the risk of AMR in mind, even if the sensitive antibody detection tests are negative.