Shirai Hiroyuki, Yashima Jun, Tojimbara Tamotsu, Honda Kazuho
Department of Transplant Surgery, International University of Health and Welfare, Atami Hospital, Shizuoka, Japan.
Department of Anatomy, Showa University School of Medicine, Tokyo, Japan.
Nephrology (Carlton). 2016 Jul;21 Suppl 1:41-3. doi: 10.1111/nep.12769.
Thrombotic microangiopathy (TMA) after kidney transplantation has various aetiologies, including acute antibody-mediated rejection, bacterial or viral infection and immunosuppressive drugs, particularly calcineurin inhibitors. We present the case of a 28-year-old woman who developed TMA 30 months after the transplantation of an ABO-incompatible kidney from a living unrelated donor. The patient developed a sudden onset of allograft renal dysfunction and became uremic. She was transferred to our institution from a community hospital with strongly suspected acute allograft rejection. Intensive treatments for both T- and B-cell mediated acute rejection, including steroid pulse therapy, double-filtration plasmapheresis, antithymocyte globulin (1.5 mg/kg × 14 days) and rituximab (100 mg), were initiated during haemodialysis. However, her renal allograft function did not improve. Histopathological analysis 8 days after the treatment indicated TMA, despite the absence of apparent acute T-cell- or acute antibody-mediated rejection. There were no symptoms of infectious diseases, such as intestinal haemorrhagic colitis or viral infection. We concluded that the use of oral contraceptives, which had been initiated 3 weeks before TMA onset for the treatment of irregular vaginal bleeding, was the aetiologic agent.
肾移植后血栓性微血管病（TMA）有多种病因，包括急性抗体介导的排斥反应、细菌或病毒感染以及免疫抑制药物，尤其是钙调神经磷酸酶抑制剂。我们报告一例28岁女性病例，该患者在接受来自非亲属活体供者的ABO血型不相容肾移植30个月后发生了TMA。患者突然出现移植肾肾功能不全并发展为尿毒症。她从一家社区医院转入我院，当时高度怀疑为急性移植肾排斥反应。在血液透析期间，启动了针对T细胞和B细胞介导的急性排斥反应的强化治疗，包括类固醇冲击治疗、双重滤过血浆置换、抗胸腺细胞球蛋白（1.5mg/kg×14天）和利妥昔单抗（100mg）。然而，她的移植肾功能并未改善。治疗8天后的组织病理学分析显示为TMA，尽管没有明显的急性T细胞或急性抗体介导的排斥反应。没有肠道出血性结肠炎或病毒感染等传染病症状。我们得出结论，在TMA发病前3周开始使用口服避孕药治疗不规则阴道出血是病因。
