Departamento de Medicina, Escuela de Medicina, Universidad de Valparaíso, Valparaiso, Chile.
Clin Exp Nephrol. 2011 Apr;15(2):308-11. doi: 10.1007/s10157-010-0387-8. Epub 2010 Dec 10.
A 31-year-old woman with nephronophthisis received a cadaveric kidney transplant, and was immunosuppressed with cyclosporine, azathioprine and steroids. Twelve days after transplant a biopsy showed acute rejection with vascular damage. She was treated with 3 pulses of methylprednisolone and change of immunosuppression to mycophenolate mofetil and tacrolimus, without improving graft function. At day 21, a second biopsy showed accentuation of interstitial and vascular rejection. Antibody-mediated rejection was suspected and plasmapheresis and rituximab were prescribed. Graft function improved rapidly. Staining for C4d was negative and there were no circulating antibodies against the donor. In the interstitial infiltrate there were clusters of B lymphocytes that accounted for 40% of cells, which was thought to be an ominous sign, as it has been associated with poor graft outcome. Acute T-cell-mediated rejection grade III (Banff 07) was diagnosed. Thirty-nine months after transplant her kidney function is stable with no other complication. This clinical case generates the hypothesis that rituximab may have a beneficial role in the therapy of acute cellular rejection when there are clusters of B lymphocytes in the infiltrate and a good response has not been obtained to conventional anti-rejection therapy.
一位 31 岁的女性患有肾髓质囊性病变，接受了尸体肾脏移植，并接受环孢素、硫唑嘌呤和类固醇免疫抑制治疗。移植后 12 天，活检显示伴有血管损伤的急性排斥反应。她接受了 3 个疗程的甲泼尼龙冲击治疗，并将免疫抑制药物改为霉酚酸酯和他克莫司，但移植物功能没有改善。第 21 天，第二次活检显示间质和血管排斥反应加重。怀疑存在抗体介导的排斥反应，因此给予血浆置换和利妥昔单抗治疗。移植物功能迅速改善。C4d 染色为阴性，也没有针对供体的循环抗体。在间质浸润中存在 B 淋巴细胞簇，占细胞的 40%，这被认为是一个不祥的迹象，因为它与移植物预后不良有关。诊断为急性 T 细胞介导的排斥反应 III 级（Banff 07）。移植后 39 个月，她的肾功能稳定，没有其他并发症。这个临床病例提出了一个假设，即当浸润中有 B 淋巴细胞簇且常规抗排斥治疗反应不佳时，利妥昔单抗可能在急性细胞排斥反应的治疗中发挥有益作用。
