Okada Mari, Kamei Koichi, Matsuoka Kentaro, Ito Shuichi
Department of Pediatrics, Musashino Red Cross Hospital, 1-26-1, Kyonan-cho, Musashino, Tokyo, 180-8610, Japan.
Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan.
CEN Case Rep. 2018 Nov;7(2):288-291. doi: 10.1007/s13730-018-0344-z. Epub 2018 Jun 12.
Acute rejection is a major cause of graft loss in patients with kidney transplantations. However, the appropriate timing for performing a biopsy is often difficult to gauge in a clinical settings. We encountered an 8-year-old boy in whom antibody mediated rejection (AMR) associated with de novo donor-specific antibody (DSA) developed shortly after an episode of type IA acute cellular rejection (ACR). He had received a preemptive ABO-compatible kidney transplantation due to bilateral renal hypoplasia. Type IA ACR developed 2 months after transplantation and was successfully treated with methylprednisolone pulse therapy (MPT) and gusperimus hydrochloride. However, 4 months after transplantation, his serum creatinine level increased again. We decided to perform an additional biopsy despite having done the previous biopsy only a short time ago. Marked infiltration of inflammation cells in the peritubular capillaries (PTCs) with positive C4d staining was observed. AMR associated with de novo DSA with type IB ACR was newly diagnosed because DSA was not detected and the crossmatch test was negative before transplantation. He immediately received two courses of plasma exchange (PE), three courses of MPT, and rituximab. He confessed to non-adherence and underwent a patient education program with his family again. To date, no cases of AMR associated with de novo DSA shortly after ACR have been reported. Our experience lends support to the 'episode biopsy' method in which a biopsy is performed for each episode of serum creatinine increase as recommended by The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Working Group.
急性排斥反应是肾移植患者移植肾丢失的主要原因。然而，在临床环境中，进行活检的合适时机往往难以判断。我们遇到一名8岁男孩，在IA型急性细胞排斥反应（ACR）发作后不久，出现了与新发供体特异性抗体（DSA）相关的抗体介导的排斥反应（AMR）。由于双侧肾发育不全，他接受了一次抢先的ABO相容肾移植。移植后2个月发生IA型ACR，通过甲泼尼龙冲击疗法（MPT）和盐酸胍立莫司成功治疗。然而，移植后4个月，他的血清肌酐水平再次升高。尽管不久前刚做过一次活检，我们还是决定再次进行活检。观察到肾小管周围毛细血管（PTC）中有明显的炎症细胞浸润，C4d染色呈阳性。由于移植前未检测到DSA且交叉配型试验为阴性，新诊断为与新发DSA相关的AMR合并IB型ACR。他立即接受了两个疗程的血浆置换（PE）、三个疗程的MPT和利妥昔单抗治疗。他承认存在不依从情况，并再次与家人一起参加了患者教育项目。迄今为止，尚未有关于ACR后不久出现与新发DSA相关的AMR病例的报道。我们的经验支持了“发作期活检”方法，即按照《肾脏病：改善全球预后》（KDIGO）移植工作组的建议，在血清肌酐每升高一次发作时进行活检。
