title: Ultra-late antibody-mediated rejection 30 years after a living-related renal allograft.
abstract: Antibody-mediated renal allograft rejection has become increasingly recognized and more clearly defined through the use of flow cytometry cross-matching and the deposition of C4d in renal allograft biopsies. All of the cases reported thus far have developed an antibody within 10 years of transplantation, and many lacked HLA and/or donor specificity. The present patient developed an anti-HLA donor-specific antibody between the 22nd and 30th year after a living-related renal transplant. At the 30th year post-transplantation, she experienced a rise in the serum creatinine from 0.7 to 1.9 mg/dL associated with transplant biopsy C4d deposition in peritubular capillaries and glomeruli. After the replacement of azathioprine with mycophenolate mofetil, and six apheresis treatments followed by two infusions of IVIG, the renal function stabilized at 1.9 mg/dL, 33 years after transplantation. Antibody-mediated rejection must be considered as a possible cause or renal allograft dysfunction at all time periods after transplantation.
authors.affiliation: Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: David
authors.initials: D
authors.lastname: Weinstein
authors.forename: William E
authors.initials: WE
authors.lastname: Braun
authors.forename: Daniel
authors.initials: D
authors.lastname: Cook
authors.forename: James T
authors.initials: JT
authors.lastname: McMahon
authors.forename: Jonathan
authors.initials: J
authors.lastname: Myles
authors.forename: Deborah
authors.initials: D
authors.lastname: Protiva
mesh_terms: D000293:Adolescent; D000906:Antibodies / Q000737:chemistry; D000917:Antibody Formation; D001379:Azathioprine / Q000008:administration & dosage / Q000627:therapeutic use; D001706:Biopsy; D015935:Complement C4b / Q000096:biosynthesis; D005260:Female; D005434:Flow Cytometry; D005919:Glomerular Filtration Rate; D006084:Graft Rejection; D006085:Graft Survival; D006680:HLA Antigens / Q000737:chemistry; D006650:Histocompatibility Testing; D006801:Humans; D007136:Immunoglobulins / Q000737:chemistry; D016756:Immunoglobulins, Intravenous / Q000737:chemistry; D007668:Kidney / Q000378:metabolism; D016030:Kidney Transplantation; D019520:Living Donors; D008214:Lymphocytes / Q000166:cytology; D008775:Methylprednisolone / Q000008:administration & dosage; D008854:Microscopy, Electron; D008856:Microscopy, Fluorescence; D009173:Mycophenolic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000627:therapeutic use; D010446:Peptide Fragments / Q000096:biosynthesis; D010641:Phenotype; D011241:Prednisone / Q000627:therapeutic use; D013997:Time Factors; D014184:Transplantation, Homologous / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000906:Antibodies; D006680:HLA Antigens; D007136:Immunoglobulins; D016756:Immunoglobulins, Intravenous; D010446:Peptide Fragments; D015935:Complement C4b; C032261:complement C4d; D009173:Mycophenolic Acid; D001379:Azathioprine; D011241:Prednisone; D008775:Methylprednisolone