A 33-year-old man was admitted for an episode biopsy; he had a serum creatinine (S-Cr) level of 5.7 mg/dL 1 year following primary kidney transplantation. Histological features included two distinct entities: (1) a focal, aggressive tubulointerstitial inflammatory cell (predominantly plasma cells) infiltration with moderate tubulitis; and (2) inflammatory cell infiltration (including neutrophils) in peritubular capillaries. Substantial laboratory examination showed that the patient had donor-specific antibodies for DQ4 and DQ6. Considering both the histological and laboratory findings, we diagnosed him with plasma cell-rich rejection accompanied by acute antibody-mediated rejection.
We started 3 days of consecutive steroid pulse CP-868596 mouse therapy three times every 2 weeks for the former and plasma exchange with intravenous immunoglobulin (IVIG) for the latter INCB024360 supplier histological feature. One month after treatment, a second allograft biopsy showed excellent responses to treatment for plasma cell-rich rejection, but moderate, acute antibody-mediated rejection remained. Therefore, we added plasma exchange with IVIG again. After
treatment, allograft function was stable, with an S-Cr level of 2.8 mg/dL. This case report demonstrates the difficulty of the diagnosis of, and treatment for, plasma cell-rich rejection accompanied by acute antibody-mediated rejection in a patient with ABO-incompatible kidney transplantation. We also include a review of the related literature. Both plasma cell-rich rejection (PCAR) and acute antibody-mediated rejection (AMR) remain refractory rejection entities in spite of the recent development and establishment of immunosuppressive therapy. The former is characterized by the presence of mature plasma cells that comprise more than 10% of the inflammatory cell
infiltration in a renal allograft. PCAR is a rare type of rejection noted in approximately 5–14% of patients with biopsy-proven acute rejection, but graft survival is poor and standard therapeutic options have yet to be generally established. The latter is a well-recognized type of rejection that is due in large part to antibodies to human leukocyte antigen (HLA) alleles. Recent studies have focused on not only HLA-DR compatibility, selleck chemicals but also on that of HLA-DQ, since de novo DQ donor-specific antibodies (DSAbs) are the predominant HLA class II DSAbs found after transplantation. We report here a refractory case of PCAR accompanied by AMR due to de novo DQ DSAbs 1 year after ABO-incompatible, living-related kidney transplantation. A 33-year-old Japanese man was admitted to our hospital for an episode biopsy 1 year following primary kidney transplantation. He was diagnosed with IgA nephropathy at the age of 31 years and received a living-related kidney transplantation at the age of 32 from his mother. ABO blood types were incompatible, and HLA alleles were mismatched at two loci, B52 and DR8.