title: A case of accelerated acute rejection after ABO-compatible living unrelated kidney transplantation.
abstract: 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.
authors: Division of Kidney and Hypertension, Department of Internal Medicine, Kashiwa Hospital, The Jikei University School of Medicine, Chiba, Japan. nana77m@jikei.ac.jp
authors: Nanae
authors: N
authors: Matsuo
authors: Hiroyasu
authors: H
authors: Yamamoto
authors: Akimitsu
authors: A
authors: Kobayashi
authors: Izumi
authors: I
authors: Yamamoto
authors: Jun
authors: J
authors: Mitome
authors: Yukio
authors: Y
authors: Maruyama
authors: Hiroshi
authors: H
authors: Hayakawa
authors: Yoichi
authors: Y
authors: Miyazaki
authors: Yasunori
authors: Y
authors: Utsunomiya
authors: Tatsuo
authors: T
authors: Hosoya
authors: Yutaka
authors: Y
authors: Yamaguchi
mesh_terms: D000017:ABO Blood-Group System / Q000276:immunology*; D000208:Acute Disease; D001707:Biopsy, Needle; D005260:Female; D005434:Flow Cytometry; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000097:blood* / Q000188:drug therapy / Q000473:pathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016030:Kidney Transplantation / Q000276:immunology* / Q000473:pathology; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D018454:Spouses
chemical_list: D000017:ABO Blood-Group System; D007166:Immunosuppressive Agents