title: Acute antibody-mediated rejection possibly due to anti-human leukocyte antigen DQB1 antibodies after renal transplantation - case report.
abstract: A 61-year-old Japanese woman, who had undergone hemodialysis because of chronic glomerulonephritis, received a living renal transplant from her ABO blood type-compatible spouse. HLA typing of A, B and DRB showed 3/6 mismatches. Complement-dependent cytotoxicity crossmatches, HLA antibody screening with the use of flow panel reactive antibody (PRA), and flow cytometry crossmatches (FCXM) were all negative. Tacrolimus, mycophenolate mofetil, methylprednisolone (MP), and basiliximab induction were used as the standard immunosuppressive therapy. After renal transplantation, her serum creatinine level favorably decreased, but urine output was not sufficiently obtained, contrary to our expectations. Doppler sonography revealed disappearance of diastolic arterial flow on postoperative day 2. The episode biopsy showed acute antibody-mediated rejection (AMR) based on the current Banff classification, although FCXM and flow PRA were still negative. To determine the cause of acute AMR, we expanded the HLA typing at high resolution levels to Cw, DQB1, and DPB1. Retrospective analysis of perioperative sera demonstrated the presence of low levels of donor-specific HLA IgG and moderate levels of IgM antibody against DQB1 before transplantation. There was an elevation of IgM antibody at the time of rejection, whereas IgG antibody showed no remarkable change. AMR was successfully treated with plasma exchange, low-dose intravenous immunoglobulin, high-dose intravenous MP pulse, and rituximab.
authors.affiliation: Department of Surgery, Kumamoto Red Cross Hospital, Kumamoto, Japan; Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan. Electronic address: yama335@gmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Yamanaga
authors.affiliation: Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors.forename: Y
authors.initials: Y
authors.lastname: Watarai
authors.affiliation: Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors.forename: A
authors.initials: A
authors.lastname: Takeda
authors.affiliation: Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors.forename: T
authors.initials: T
authors.lastname: Yamamoto
authors.affiliation: Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors.forename: T
authors.initials: T
authors.lastname: Hiramitsu
authors.affiliation: Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors.forename: M
authors.initials: M
authors.lastname: Tsujita
authors.affiliation: Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors.forename: N
authors.initials: N
authors.lastname: Goto
authors.affiliation: Department of Transplant Surgery, Aichi Medical University, Nagakute, Japan.
authors.forename: K
authors.initials: K
authors.lastname: Uchida
authors.affiliation: Department of Transplant Surgery, Masuko Memorial Hospital, Nagoya, Japan.
authors.forename: A
authors.initials: A
authors.lastname: Katayama
authors.affiliation: Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors.forename: K
authors.initials: K
authors.lastname: Morozumi
authors.affiliation: Department of Transplant Immunology, Nagoya University School of Medicine, Nagoya, Japan.
authors.forename: T
authors.initials: T
authors.lastname: Kobayashi
mesh_terms: D001323:Autoantibodies / Q000276:immunology*; D005260:Female; D005434:Flow Cytometry; D006084:Graft Rejection / Q000276:immunology*; D059866:HLA-DQ beta-Chains / Q000276:immunology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D007680:Kidney Neoplasms / Q000276:immunology*; D008875:Middle Aged
chemical_list: D001323:Autoantibodies; D059866:HLA-DQ beta-Chains; C069051:HLA-DQB1 antigen; D007166:Immunosuppressive Agents