title: A suspected case of plasma cell-rich acute renal transplant rejection associated with de novo donor-specific antibody.
abstract: A kidney transplant case with de novo donor-specific antibody showed monoclonal plasma cell infiltration into the graft with ABO incompatibility. Three years after transplantation, the patient's graft function suddenly deteriorated. Interstitial edema and the predominant infiltration of inflammatory plasma cells with kappa chain monoclonality were observed in biopsy specimens. The in situ hybridization of Epstein-Barr virus was negative and post-transplant lymphoproliferative disorder was not evident from radiological examinations. On laboratory examination, the patient had de novo donor-specific antibody for HLA-DQ. We suspected plasma cell-rich acute rejection for which methylprednisolone pulse therapy, plasma exchange, rituximab, and 15-deoxyspergualin were given. In the ensuing biopsy, the degree of plasma cell infiltration was similar to the first biopsy; however, kappa chain monoclonality relatively weakened. Owing to resistance to these treatments, intravenous immunoglobulin (IVIG) (0.5 g/kg/day) was added. The serum creatinine level gradually declined to 3.1 mg/dL; however, it increased up to 3.6 mg/dL again. In the final biopsy, the infiltrated plasma cells disappeared but severe interstitial fibrosis developed. This case showed difficulty in the diagnosis and treatment of plasma cell-rich acute rejection. A detailed consideration of this case may be helpful in understanding the clinical features and pathogenesis of this condition.
authors.affiliation: Division of Nephrology, Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan.
authors.forename: Mikiko
authors.initials: M
authors.lastname: Yoshikawa
authors.affiliation: Division of Nephrology, Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan.
authors.forename: Ken
authors.initials: K
authors.lastname: Kitamura
authors.affiliation: Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Ishimura
authors.affiliation: Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan.
authors.forename: Shigeo
authors.initials: S
authors.lastname: Hara
authors.affiliation: Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Fujisawa
authors.affiliation: Division of Nephrology, Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan.
authors.forename: Shinichi
authors.initials: S
authors.lastname: Nishi
mesh_terms: D000017:ABO Blood-Group System / Q000276:immunology; D000208:Acute Disease; D000328:Adult; D001706:Biopsy; D001787:Blood Group Incompatibility / Q000276:immunology; D005355:Fibrosis; D006084:Graft Rejection / Q000188:drug therapy / Q000276:immunology* / Q000473:pathology; D006683:HLA-DQ Antigens / Q000276:immunology*; D006650:Histocompatibility Testing; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007518:Isoantibodies / Q000276:immunology*; D007668:Kidney / Q000187:drug effects / Q000276:immunology* / Q000473:pathology; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D010950:Plasma Cells / Q000187:drug effects / Q000276:immunology*; D011237:Predictive Value of Tests; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000017:ABO Blood-Group System; D006683:HLA-DQ Antigens; D007166:Immunosuppressive Agents; D007518:Isoantibodies
keywords: kidney transplantation; plasma cell-rich rejection; post-transplant lymphoproliferative disorder