title: Rituximab in the treatment of acute cellular rejection of renal allograft with CD20-positive clusters in the infiltrate.
abstract: A 31-year-old woman with nephronophthisis received a cadaveric kidney transplant, and was immunosuppressed with cyclosporine, azathioprine and steroids. Twelve days after transplant a biopsy showed acute rejection with vascular damage. She was treated with 3 pulses of methylprednisolone and change of immunosuppression to mycophenolate mofetil and tacrolimus, without improving graft function. At day 21, a second biopsy showed accentuation of interstitial and vascular rejection. Antibody-mediated rejection was suspected and plasmapheresis and rituximab were prescribed. Graft function improved rapidly. Staining for C4d was negative and there were no circulating antibodies against the donor. In the interstitial infiltrate there were clusters of B lymphocytes that accounted for 40% of cells, which was thought to be an ominous sign, as it has been associated with poor graft outcome. Acute T-cell-mediated rejection grade III (Banff 07) was diagnosed. Thirty-nine months after transplant her kidney function is stable with no other complication. This clinical case generates the hypothesis that rituximab may have a beneficial role in the therapy of acute cellular rejection when there are clusters of B lymphocytes in the infiltrate and a good response has not been obtained to conventional anti-rejection therapy.
authors.affiliation: Departamento de Medicina, Escuela de Medicina, Universidad de Valparaíso, Valparaiso, Chile. jvegastieb@gmail.com
authors.forename: Jorge
authors.initials: J
authors.lastname: Vega
authors.forename: Helmuth
authors.initials: H
authors.lastname: Goecke
authors.forename: Alejandra
authors.initials: A
authors.lastname: Carrasco
authors.forename: Carlos
authors.initials: C
authors.lastname: Escobar
authors.forename: Max
authors.initials: M
authors.lastname: Escobar
authors.forename: Roberto
authors.initials: R
authors.lastname: Espinosa
authors.forename: Gonzalo
authors.initials: G
authors.lastname: Méndez
authors.forename: María
authors.initials: M
authors.lastname: de Los Ángeles Rodríguez
mesh_terms: D000328:Adult; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use*; D018951:Antigens, CD20 / Q000276:immunology; D001402:B-Lymphocytes / Q000276:immunology; D005260:Female; D006084:Graft Rejection / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016030:Kidney Transplantation / Q000473:pathology; D009173:Mycophenolic Acid / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000069283:Rituximab; D013601:T-Lymphocytes / Q000276:immunology
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D018951:Antigens, CD20; D007166:Immunosuppressive Agents; D000069283:Rituximab; D009173:Mycophenolic Acid