Halim Medhat Abdel, Al-Otaibi Torki, Al-Waheeb Salah, Tawab Khaled Abdel, El Kholy Osama, Nair Prasad, Said Tarek, Narayanan Nampoory M R
Hamed Alessa Organ Transplantation Center, Mubarak Al-Kabeer Hospital, Kuwait.
Saudi J Kidney Dis Transpl. 2010 Nov;21(6):1111-4.
Acute antibody mediated rejection (AMR) is rarely reported as a long-term com-plication of renal transplantation, and it can present on top of another chronic pathology affecting the graft. A 45-year-old gentleman with chronic kidney disease due to unknown etiology received renal transplantation from his sister with 4 HLA mismatches. He received antithymocte globulin induction therapy and was maintained on steroids, azathioprine (AZA) and cyclosporine A (CsA). Up to eight years post-transplantation he was clinically and biochemically stable. He lost follow-up for about one year, and then presented with nephritic nephrotic syndrome and rise of serum creatinine (SCr.) to 210 μmol/L. Graft biopsy revealed picture suggestive of acute AMR on top of de novo membranoprolipherative glomerulonephritis (MPGN) with focal crescent formation, diffuse immune complex deposition and peritubular capillaries C4d positivity. Anti-HLA donor specific antibodies were highly positive for B and T cells class I and class II. The patient was treated with intravenous immunoglobulin, plasma exchange and anti-CD20 (rituximab). AZA was changed to mycophenolate mofetil and CsA to tacrolimus. He had partial response, but SCr. continued at 220 μmol/L.
急性抗体介导的排斥反应（AMR）作为肾移植的长期并发症鲜有报道，且它可能出现在影响移植肾的另一种慢性病变之上。一名45岁病因不明的慢性肾脏病男性患者接受了来自其妹妹的肾移植，有4个HLA错配。他接受了抗胸腺细胞球蛋白诱导治疗，并维持使用类固醇、硫唑嘌呤（AZA）和环孢素A（CsA）。移植后长达八年，他在临床和生化方面都保持稳定。他失访了约一年，随后出现肾炎性肾病综合征，血清肌酐（SCr）升至210μmol/L。移植肾活检显示，在新发膜增生性肾小球肾炎（MPGN）伴局灶性新月体形成、弥漫性免疫复合物沉积和肾小管周围毛细血管C4d阳性的基础上，有提示急性AMR的表现。抗HLA供体特异性抗体对I类和II类B细胞和T细胞呈高度阳性。该患者接受了静脉注射免疫球蛋白、血浆置换和抗CD20（利妥昔单抗）治疗。AZA换成了霉酚酸酯，CsA换成了他克莫司。他有部分反应，但SCr仍维持在220μmol/L。
