J Korean Soc Transplant.  2012 Jun;26(2):125-130.

A Case of Acute Antibody-Mediated Rejection Developed after Pretreatment with Rituximab and Plasma Exchange in a Highly-Sensitized Recipient with a Deceased Donor Kidney

• Kim SM
• Oh JS
• Sin YH
• Kim JK
• Park JI
• Huh K
• Kim YJ

Abstract

Acute antibody-mediated rejection is the major cause of graft failure in the early stage of kidney transplantation. Preoperative treatment and early diagnosis of acute rejection is very important to prevent graft loss in sensitized patients. High panel reactive antibody (PRA) means a likelihood of acute rejection, and the recipient of high PRA needs adequate pretreatment for kidney transplantation. However, there is not sufficient time and chances for desensitization in deceased kidney transplants. We report a successful renal transplant outcome in a 47-year-old-woman with high PRA levels (Class I 97.5%, Class II 36.7%). The cross match was negative on the CDC (ELISA) and flowcytometric methods. Plasma exchange was performed on the recipient before transplantation (fresh frozen plasma replacement, 1.3 plasma volume) and immediately after plasma exchange she was given 200 mg of rituximab. She received basiliximab and methyl prednisolone induction therapy and was maintained on steroids, mycophenolate mofetil, and tacrolimus. Graft function was normal immediately after transplantation, but decreased urinary output and elevated serum creatinine was noted on POD 5. On POD 6, a graft biopsy revealed acute cellular rejection (Type IIa) and antibody-mediated rejection (Type II). On 9~13 days after transplantation, additional plasma exchange was performed every other day, and steroid pulse therapy was performed 3 times. After normalization of urinary output and serum creatinine, the patient was discharged and is being followed up on. In conclusion, immunologically careful preparation and pretransplant treatment may be needed on the negative cross match in cadaveric kidney recipients with high levels of PRA.

Keyword

Kidney transplantation; Cadaver; Rituximab; Graft rejection; Immunization

MeSH Terms

Antibodies, Monoclonal
Antibodies, Monoclonal, Murine-Derived
Biopsy
Cadaver
Centers for Disease Control and Prevention (U.S.)
Creatinine
Early Diagnosis
Graft Rejection
Humans
Immunization
Kidney
Kidney Transplantation
Mycophenolic Acid
Plasma
Plasma Exchange
Prednisolone
Recombinant Fusion Proteins
Rejection (Psychology)
Rituximab
Steroids
Tacrolimus
Tissue Donors
Transplants
Antibodies, Monoclonal
Antibodies, Monoclonal, Murine-Derived
Creatinine
Mycophenolic Acid
Prednisolone
Recombinant Fusion Proteins
Steroids
Tacrolimus

Figure

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  Fig. 1 Clinical course; MPDS pulse, methylprednisolone 250 mg iv bid for 3 days; plasmapheresis, 1.3 plasma volume, fresh frozen plasma replacement solution; Rituximab 200 mg single infusion. Abbreviations: PP/IVIG, plasmapheresis with low dose intravenous immune globulin; RTX, rituximab; Bx., biopsy; MPDS, methyl prednisolone; SCr, serum creatinine; VRE, vancomycin resistant enterococcus.

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  Fig. 2 Leukocytes infiltration is mainly in the peritubular capillaries. Tubulitis is rarely seen (PAS, ×200).

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  Fig. 3 Lymphocytes are underneath the endothelium in large artery (PAS, ×200).

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  Fig. 4 Lymphocytes infiltration in glomerular capillary lumina (PAS, ×200).

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  Fig. 5 Immunofluorescence examination reveals positive along the peritubulare capillary walls (C4d, ×200).

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