title: A refractory case of subclinical antibody-mediated rejection due to anti-HLA-DQ antibody in a kidney transplant patient.
abstract: We herein report a refractory case of subclinical antibody-mediated rejection (AMR) due to anti-HLA-DQ antibody in a kidney transplant patient. A 45-year-old man was admitted for a protocol biopsy; he had a serum creatinine (S-Cr) level of 1.8 mg/dL 3 years following primary kidney transplantation. Histological examination revealed moderate to severe inflammatory cell infiltration in the peritubular capillaries. Thorough laboratory examination showed that the patient had donor-specific antibodies (DSAbs) to DR9 and DQ9. Considering both the histological and laboratory findings, we diagnosed acute antibody-mediated rejection. The patient underwent 3 days of consecutive steroid pulse therapy, intravenous immunoglobulin (IVIG), and plasma exchange. We also administered rituximab (200 mg/body). Six months after the treatment, a second allograft biopsy revealed the progression of interstitial fibrosis and tubular atrophy and persistence of mild peritubular capillaritis. Further analysis showed that the anti-DR9 antibodies had disappeared, but that the mean fluorescence intensity value of the anti-DQ9 antibodies had increased. Therefore, we repeated the plasma exchange and IVIG. Allograft function was stable throughout the course of treatment, and the S-Cr level remained at 1.8 mg/dL. This case report demonstrates the difficulty of treating AMR due to the presence of anti-DQ DSAbs and the necessity for subsequent therapies in refractory cases.
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Toshinari
authors.initials: T
authors.lastname: Fujimoto
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Yasuyuki
authors.initials: Y
authors.lastname: Nakada
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Izumi
authors.initials: I
authors.lastname: Yamamoto
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Akimitsu
authors.initials: A
authors.lastname: Kobayashi
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Yudo
authors.initials: Y
authors.lastname: Tanno
authors.affiliation: Department of Urology, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Hiroki
authors.initials: H
authors.lastname: Yamada
authors.affiliation: Department of Urology, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Miki
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Ichiro
authors.initials: I
authors.lastname: Ohkido
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Nobuo
authors.initials: N
authors.lastname: Tsuboi
authors.affiliation: Department of internal Medicine, Atsugi City Hospital, Kanagawa, Japan.
authors.forename: Hiroyasu
authors.initials: H
authors.lastname: Yamamoto
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Yokoo
mesh_terms: D064591:Allografts; D058070:Asymptomatic Diseases; D015415:Biomarkers / Q000097:blood; D001706:Biopsy; D003404:Creatinine / Q000097:blood; D006084:Graft Rejection / Q000276:immunology* / Q000473:pathology / Q000628:therapy; D006683:HLA-DQ Antigens / Q000276:immunology*; D006648:Histocompatibility; D006650:Histocompatibility Testing; D006801:Humans; D056724:Immunity, Humoral; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D007518:Isoantibodies / Q000097:blood*; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000379:methods; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D010951:Plasma Exchange; D020551:Pulse Therapy, Drug; D013256:Steroids / Q000008:administration & dosage; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D006683:HLA-DQ Antigens; C415982:HLA-DQ9 antigen; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D007518:Isoantibodies; D013256:Steroids; D003404:Creatinine
keywords: anti-HLA-DQ antibody; antibody-mediated rejection; subclinical