Late acute antibody mediated rejection after nine years of renal transplantation.
Acute antibody mediated rejection (AMR) is rarely reported as a long-term com-plication of renal transplantation, and it can present on top of another chronic pathology affecting the graft. A 45-year-old gentleman with chronic kidney disease due to unknown etiology received renal transplantation from his sister with 4 HLA mismatches. He received antithymocte globulin induction therapy and was maintained on steroids, azathioprine (AZA) and cyclosporine A (CsA). Up to eight years post-transplantation he was clinically and biochemically stable. He lost follow-up for about one year, and then presented with nephritic nephrotic syndrome and rise of serum creatinine (SCr.) to 210 μmol/L. Graft biopsy revealed picture suggestive of acute AMR on top of de novo membranoprolipherative glomerulonephritis (MPGN) with focal crescent formation, diffuse immune complex deposition and peritubular capillaries C4d positivity. Anti-HLA donor specific antibodies were highly positive for B and T cells class I and class II. The patient was treated with intravenous immunoglobulin, plasma exchange and anti-CD20 (rituximab). AZA was changed to mycophenolate mofetil and CsA to tacrolimus. He had partial response, but SCr. continued at 220 μmol/L.
Hamed Alessa Organ Transplantation Center, Mubarak Al-Kabeer Hospital, Kuwait. medhatmohamed2000@yahoo.com
Medhat Abdel
MA
Halim
Torki
T
Al-Otaibi
Salah
S
Al-Waheeb
Khaled Abdel
KA
Tawab
Osama
O
El Kholy
Prasad
P
Nair
Tarek
T
Said
M R
MR
Narayanan Nampoory
D000208:Acute Disease; D000906:Antibodies / Q000097:blood*; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D015432:Glomerulonephritis, Membranoproliferative / Q000276:immunology; D006084:Graft Rejection / Q000276:immunology* / Q000628:therapy; D006680:HLA Antigens / Q000276:immunology*; D006650:Histocompatibility Testing; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016030:Kidney Transplantation / Q000276:immunology*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D009404:Nephrotic Syndrome / Q000276:immunology; D010956:Plasmapheresis; D000069283:Rituximab; D016559:Tacrolimus / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome
D000906:Antibodies; D058846:Antibodies, Monoclonal, Murine-Derived; D006680:HLA Antigens; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D000069283:Rituximab; D009173:Mycophenolic Acid; D016559:Tacrolimus