title: Accelerated rejection, thrombosis, and graft failure with angiotensin II type 1 receptor antibodies.
abstract: BACKGROUND
  Angiotensin II type 1 receptor antibodies (AT1R-Abs) have been implicated in renal transplant rejection and failure; however, the mechanism of allograft damage, patterns of clinical presentation, and response to desensitization of AT1R-Abs have not been clearly established.
  
  
  METHODS
  We present the case of a 7-year-old boy with preformed AT1R-Abs who developed accelerated vascular and cellular rejection and renal allograft thrombosis despite desensitization and treatment with angiotensin receptor blockade. Although an association between AT1R-Abs and microvascular occlusion has been previously described, we are the first to describe an association between AT1R-Abs and renal artery thrombosis, leading to devastating early allograft failure.
  
  
  CONCLUSIONS
  This case highlights the risk of allograft thrombosis associated with AT1R-Abs and illustrates that previous treatments utilized for AT1R-Abs may not always be effective. Further studies are needed to better characterize the mechanisms of AT1R-Ab pathogenesis and to establish safe levels of AT1R-Abs both pre- and post-transplantation. Given the outcome of this patient and the evidence of pro-coagulatory effects of AT1R-Abs, we suggest that the presence of AT1R-Ab may be a risk factor for thrombosis. The role of treatment with anti-coagulation and novel immunomodulatory agents such as tocilizumab and bortezomib require further investigation.
authors.affiliation: Department of Pediatrics, Division of Nephrology, University of California Los Angeles, David Geffen School of Medicine at UCLA, PO Box 951752, Los Angeles, CA, 90095, USA, mpearl@mednet.ucla.edu.
authors.forename: Meghan H
authors.initials: MH
authors.lastname: Pearl
authors.forename: Richard K
authors.initials: RK
authors.lastname: Leuchter
authors.forename: Elaine F
authors.initials: EF
authors.lastname: Reed
authors.forename: Qiuheng
authors.initials: Q
authors.lastname: Zhang
authors.forename: Robert B
authors.initials: RB
authors.lastname: Ettenger
authors.forename: Eileen W
authors.initials: EW
authors.lastname: Tsai
mesh_terms: D001323:Autoantibodies / Q000009:adverse effects*; D001324:Autoantigens / Q000276:immunology; D002648:Child; D006084:Graft Rejection / Q000276:immunology*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery; D016030:Kidney Transplantation; D008297:Male; D044140:Receptor, Angiotensin, Type 1 / Q000276:immunology*; D013927:Thrombosis / Q000276:immunology
chemical_list: D001323:Autoantibodies; D001324:Autoantigens; D044140:Receptor, Angiotensin, Type 1