Matsuo Nanae, Yamamoto Hiroyasu, Kobayashi Akimitsu, Yamamoto Izumi, Mitome Jun, Maruyama Yukio, Hayakawa Hiroshi, Miyazaki Yoichi, Utsunomiya Yasunori, Hosoya Tatsuo, Yamaguchi Yutaka
Division of Kidney and Hypertension, Department of Internal Medicine, Kashiwa Hospital, The Jikei University School of Medicine, Chiba, Japan.
Clin Transplant. 2009 Aug;23 Suppl 20:23-6. doi: 10.1111/j.1399-0012.2009.01004.x.
A 59-yr-old Japanese woman with chronic renal failure caused by IgA nephropathy and antineutrophil cytoplasmic antibody (ANCA)-related glomerulonephritis underwent kidney transplantation from a living unrelated spousal donor. The blood type was compatible, while the human leukocyte antigen (HLA) typing showed a 5/6 locus mismatch. She had become pregnant twice by her donor and had never received blood transfusions. Complement-dependent cytotoxicity cross-match, flow cytometry cross-match (FCXM), and flow panel reactive antibody (PRA) were negative. She initially underwent one week of immunosuppression with mycophenolate mofetil (MMF) and double filtration plasmapheresis (DFPP) immediately before transplantation to reduce the risk of antibody-mediated rejection. Induction therapy consisted of MMF, tacrolimus (TAC), methylprednisolone (MP), and basiliximab. The allograft function was excellent immediately after the operation. However, the urine output and platelet count declined rapidly on post-operative day (POD) 3, while the serum creatinine (sCr) and lactate dehydrogenase levels rose gradually. Subsequently, we could not detect the diastolic arterial flow on Doppler sonography. We diagnosed accelerated acute rejection and treated her with plasma exchange (PEX), intravenous MP pulse therapy, and rituximab. The first episode biopsy on POD 7 revealed acute vascular rejection and acute antibody-mediated rejection (Banff score AMR II). Her urinary excretion increased beginning on POD 13, while the sCr level decreased gradually and reached 0.9 mg/dL on POD 22. In our retrospective analysis, the LAB screen detected donor-specific antibody (DSA). This case suggested that, for successful kidney transplantation in highly sensitized recipients, such as husband-to-wife spousal kidney transplantation with a history of pregnancy, we should keep the risk of AMR in mind, even if the sensitive antibody detection tests are negative.
一名59岁的日本女性，因IgA肾病和抗中性粒细胞胞浆抗体（ANCA）相关性肾小球肾炎导致慢性肾衰竭，接受了来自非亲属活体配偶供体的肾脏移植。血型匹配，但人类白细胞抗原（HLA）分型显示有5/6位点错配。她曾两次与供体受孕，且从未接受过输血。补体依赖细胞毒性交叉配型、流式细胞术交叉配型（FCXM）和流式群体反应性抗体（PRA）均为阴性。她在移植前最初接受了一周的霉酚酸酯（MMF）免疫抑制治疗，并在移植前立即进行了双重滤过血浆置换（DFPP），以降低抗体介导排斥反应的风险。诱导治疗包括MMF、他克莫司（TAC）、甲泼尼龙（MP）和巴利昔单抗。术后移植肾的功能立即良好。然而，术后第3天（POD 3）尿量和血小板计数迅速下降，而血清肌酐（sCr）和乳酸脱氢酶水平逐渐升高。随后，我们在多普勒超声检查中未检测到舒张期动脉血流。我们诊断为加速性急性排斥反应，并对她进行了血浆置换（PEX）、静脉注射MP冲击治疗和利妥昔单抗治疗。POD 7的首次活检显示急性血管排斥反应和急性抗体介导的排斥反应（班夫评分AMR II）。从POD 13开始她的尿量增加，而sCr水平逐渐下降，在POD 22时降至0.9 mg/dL。在我们的回顾性分析中，实验室筛查检测到了供体特异性抗体（DSA）。该病例表明，对于高度致敏受者的成功肾移植，如夫妻间有妊娠史的配偶肾移植，即使敏感抗体检测试验为阴性，我们也应牢记抗体介导排斥反应的风险。
