Acute antibody-Mediated rejection after kidney transplantation a case report

ACUTE ANTIBODY-MEDIATED REJECTION AFTER KIDNEY TRANSPLANTATIONA CASE REPORT Nguyễn Thu HươngPhó Hồng ĐiệpNguyễn Thị Kiên Acute antibody-mediated rejectionAn important cause of renal allograft dysfunction.Occurs in 5-10% of renal transplant patients.Risk factors: blood transfusion, previous organ transplantation,pregnancy, HLA incompatibility (>2/6). Diagnosis: DSA, C4d, and acute tissue injury caused by DSA (Banff criteria)Its treatment still remains a challenge in kidney transplantationA case reportA 11 year-old girl, ESKD due to nephrotic syndrome and treated with peritoneal dialysis for 3 years.2014 October: undergone kidney transplantation from a living donor, who is her mother .Negative Crosmatch, PRA 0%. HLA compatibility 40%. Blood transfusions: twice before transplantation.The allograft function was excellent after the operation. Immunosupressors: Methylprednisolon, Basiliximab, Neoral, MMF, Prednisolone.(Continue) On post-tranplant day 40, patient acutely presented declined urine output, high blood pressure, increased serum Creatinine and proteinuria, no fever. Performed kidney biopsy.Other tests: BK virus, CMV and EBV: negativePositive DSAKidney biopsy (2014 October)HE x 40. Difuse interstitial inflamation, dilated tubulesAtrofia of tubular endothelium Peritubular capillaritisNeutrophilsTubulitisPeritubular capillaritis C4d (+) Histophatologic diagnosis	Both acute cellular mediated rejection and antibody-mediated rejection TreatmentMethylprednisolone 1g/1,73 m2 on alternate days, 3 dose partial responseRituximab: 375mg/m2.After Rituximab treatment 5 days: renal function recovered completely Progress The patient maintained stable until July 2016, On 20 months of transplantation, she again presented allograft failure: high blood presure, decreased urine output, Ure 11.6 mmol/l, Creatinin187.3µmol/l, urine Protein/Creatinin=128mg/mmol. US: hyperechogenic kidney, dilated renal pelvis(12mm).Kidney biopsy: Both acute cellular mediated rejection and antibody-mediated rejection.Progress Methylprednisolone 1g/1,73 m2 on alternate days, 3 dose After one week: Ure: 8.5, Creatinin 86, urine Protein/Creatinin= 45mg/mmol.This month: Ure: 6.8, Creatinin 112, Proteinuria negative. Kidney biopsy (2016 July)HEBạcPASTrichomeTubulitis C4d (+)RituximabRituximab is an anti-human CD20 monoclonal antibody.Uses: treatment of Lymphoma B, rheumatoid arthritis autoimmune diseases...In transplantation: ABOi transplantation, post-transplant lymphoproliferative disorder, HLA antibody incompatible renal transplantation and acute rejectionAuthorSubjectsProtocolResultsBecker et al 2004N = 27 Adults Rej. refractory to steroids or ATG/PPSingle dose of RIT (375 mg/m2 )89% Graft survivalAverage Cr 0.95 at dischargeFaguer et al 2007N = 8 Adults AMRRIT (375 mg/m2 weekly × 4) with steroids and PP + various additional treatments10 m average follow-up Graft survival 75% Cr improved.Infection rate> 50% (CMV, BK virus, fungus)Mulley et al 2009N = 7 Adults AMRSingle-dose rituximab (500 mg) for AMR refractory to PP/low dose IVIG 20 m follow-up Cr improved 100% allograft survivalHigh rate of infection complicationKasposztas et al 2009N = 54 Adults AMRPP plus RIT ± IVIG vs PP alone ± IVIG 24 m follow-up Graft survival 90% (ritux) vs 60% (control) Lefaucher at al 200912 patients AMR375 mg/m2, two doses every 2 weeks 36 m follow-up.Graft survival 92%