title: Subclinical antibody-mediated rejection due to anti-human-leukocyte-antigen-DR53 antibody accompanied by plasma cell-rich acute rejection in a patient with cadaveric kidney transplantation.
abstract: A 56-year-old man who had undergone cadaveric kidney transplantation 21 months earlier was admitted to our hospital for a protocol biopsy; he had a serum creatinine level of 1.2 mg/dL and no proteinuria. Histological features showed two distinct entities: (i) inflammatory cell infiltration, in the glomerular and peritubular capillaries and (ii) focal, aggressive tubulointerstitial inflammatory cell infiltration, predominantly plasma cells, with mild tubulitis (Banff 13 classification: i2, t1, g2, ptc2, v0, ci1, ct1, cg0, cv0). Immunohistological studies showed mildly positive C4d immunoreactivity in the peritubular capillaries. The patient had donor specific antibody to human-leucocyte-antigen-DR53. We diagnosed him with subclinical antibody-mediated rejection accompanied by plasma cell-rich acute rejection. Both antibody-mediated rejection due to anti- human-leucocyte-antigen -DR53 antibodies and plasma cell-rich acute rejection are known to be refractory and have a poor prognosis. Thus, we started plasma exchange with intravenous immunoglobulin and rituximab for the former and 3 days of consecutive steroid pulse therapy for the latter. Three months after treatment, a follow-up allograft biopsy showed excellent responses to treatment for both histological features. This case report considers the importance of an early diagnosis and appropriate intervention for subclinical antibody-mediated rejection due to donor specific antibody to human-leucocyte-antigen-DR53 and plasma cell-rich acute rejection.
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
authors.forename: Ai
authors.initials: A
authors.lastname: Katsuma
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
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.
authors.forename: Yo
authors.initials: Y
authors.lastname: Komatsuzaki
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
authors.forename: Takahito
authors.initials: T
authors.lastname: Niikura
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
authors.forename: Mayuko
authors.initials: M
authors.lastname: Kawabe
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
authors.forename: Yusuke
authors.initials: Y
authors.lastname: Okabayashi
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
authors.forename: Takafumi
authors.initials: T
authors.lastname: Yamakawa
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
authors.forename: Haruki
authors.initials: H
authors.lastname: Katsumata
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
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.
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.
authors.forename: Yudo
authors.initials: Y
authors.lastname: Tanno
authors.affiliation: Department of Urology, The Jikei University School of Medicine, Tokyo.
authors.forename: Jun
authors.initials: J
authors.lastname: Miki
authors.affiliation: Department of Urology, The Jikei University School of Medicine, Tokyo.
authors.forename: Hiroki
authors.initials: H
authors.lastname: Yamada
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo.
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.
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.
authors.forename: Takashi
authors.initials: T
authors.lastname: Yokoo
mesh_terms: D000208:Acute Disease; D001706:Biopsy; D006084:Graft Rejection / Q000097:blood / Q000276:immunology* / Q000473:pathology / Q000628:therapy; D006085:Graft Survival; D006684:HLA-DR Antigens / Q000276:immunology*; D059845:HLA-DRB4 Chains / Q000276:immunology*; D006648:Histocompatibility; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D007518:Isoantibodies / Q000097:blood / Q000276:immunology*; D007668:Kidney / Q000187:drug effects / Q000276:immunology* / Q000473:pathology; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010950:Plasma Cells / Q000187:drug effects / Q000276:immunology* / Q000473:pathology; D010951:Plasma Exchange; D020551:Pulse Therapy, Drug; D000069283:Rituximab / Q000008:administration & dosage; D013256:Steroids / Q000008:administration & dosage; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D006684:HLA-DR Antigens; C050610:HLA-DR53; D059845:HLA-DRB4 Chains; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D007518:Isoantibodies; D013256:Steroids; D000069283:Rituximab
keywords: BK virus; acute antibody-mediated rejection; anti-HLA-DR53 antibody; cadaveric kidney transplantation; plasma cell-rich acute rejection