Probable C4d-negative accelerated acute antibody-mediated rejection due to non-HLA antibodies

• Published in: Nephrology (Carlton, Vic.) Vic.), 2015-07, Vol.20 (S2), p.75-78
• Main Authors: Niikura, Takahito, Yamamoto, Izumi, Nakada, Yasuyuki, Kamejima, Sahoko, Katsumata, Haruki, Yamakawa, Takafumi, Furuya, Maiko, Mafune, Aki, Kobayashi, Akimitsu, Tanno, Yudo, Miki, Jun, Yamada, Hiroki, Ohkido, Ichiro, Tsuboi, Nobuo, Yamamoto, Hiroyasu, Yokoo, Takashi
• Format: Article
• Language: English
• Subjects: ABO Blood-Group System - immunology; accelerated acute antibody-mediated rejection; Acute Disease; Adult; Allografts; Biopsy; Blood Group Incompatibility - immunology; C4d; Complement C4b - analysis; Drug Therapy, Combination; Graft Rejection - immunology; Graft Rejection - pathology; Graft Rejection - therapy; Histocompatibility; Humans; Immunity, Humoral; Immunosuppressive Agents - administration & dosage; Isoantibodies - blood; Kidney - immunology; Kidney - pathology; Kidney Transplantation - adverse effects; Male; non-HLA antibodies; Peptide Fragments - analysis; Plasma Exchange; Pulse Therapy, Drug; Steroids - administration & dosage; Time Factors; Treatment Outcome
• ISSN: 1320-5358; 1440-1797
• DOI: 10.1111/nep.12467

We report a case of probable C4d‐negative accelerated acute antibody‐mediated rejection due to non‐HLA antibodies. A 44 year‐old male was admitted to our hospital for a kidney transplant. The donor, his wife, was an ABO minor mismatch (blood type O to A) and had Gitelman syndrome. Graft function was delayed; his serum creatinine level was 10.1 mg/dL at 3 days after transplantation. Open biopsy was performed immediately; no venous thrombosis was observed during surgery. Histology revealed moderate peritubular capillaritis and mild glomerulitis without C4d immunoreactivity. Flow cytometric crossmatching was positive, but no panel‐reactive antibodies against HLA or donor‐specific antibodies (DSAbs) to major histocompatibility complex class I‐related chain A (MICA) were detected. Taken together, we diagnosed him with probable C4d‐negative accelerated antibody‐mediated rejection due to non‐HLA, non‐MICA antibodies, the patient was treated with steroid pulse therapy (methylprednisolone 500 mg/day for 3 days), plasma exchange, intravenous immunoglobulin (40 g/body), and rituximab (200 mg/body) were performed. Biopsy at 58 days after transplantation, at which time S‐Cr levels were 1.56 mg/dL, found no evidence of rejection. This case, presented with a review of relevant literature, demonstrates that probable C4d‐negative accelerated acute AMR can result from non‐HLA antibodies.