Journal List > J Korean Soc Transplant > v.25(2) > 1034337

J Korean Soc Transplant. 2011 Jun;25(2):116-122. Korean.
Published online June 30, 2011.
Copyright © 2011 The Korean Society for Transplantation
A Case of Late Mixed Acute Humoral and Cellular Rejection Successfully Treated with Rituximab, Plasmapheresis and IVIg
Seong Min Kim, M.D.,1 Joon Seok Oh, M.D.,1 Jee Min Jun, M.D.,1 Yong Kee Park, M.D.,1 Yong Hun Sin, M.D.,1 Joong Kyung Kim, M.D.,1 Kill Huh, M.D.,2 and Yong Jin Kim, M.D.3
1Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea.
2Department of General Surgery, Bong Seng Memorial Hospital, Busan, Korea.
3Department of Pathology, Yeungnam University College of Medicine, Daegu, Korea.

Corresponding author (Email: )
Received April 16, 2011; Revised May 26, 2011; Accepted May 31, 2011.


Acute antibody-mediated rejection (AMR) developing simultaneously with acute cellular rejection has been rarely reported as a long-term complication of renal transplantation, and it can present on top of another chronic pathology affecting the graft. A 51-year-old female patient with chronic kidney disease of unknown etiology received renal transplantation 12 years ago from a living unrelated donor with 3 HLA mismatches. She received induction therapy with methylprednisolone and was maintained on steroids, mycophenolate mofetil and cyclosporine A (CsA). For a period of twelve years post-transplantation, she was clinically and biochemically stable. She presented with a rise in serum creatinine (SCr.) from 1.3 mg/dL to 2.4 mg/dL but did not have proteinuria. Graft biopsy revealed findings suggestive of acute cellular rejection on top of antibody-mediated rejection (type II) and chronic calcineurin inhibitor toxicity. Panel reactive antibody (PRA) test levels were 3.6%, 91.7% for class I and II respectively. The patient was treated with high-dose methylprednisolone for 3 days but serum creatinine was not fully normalised. After 2 weeks from initial methyl-PDS pulse therapy, she received intravenous immunoglobulin, plasma exchange and anti-CD20 (rituximab). Cyclosporine was changed to tacrolimus. She achieved a complete response, and SCr. was maintained at 1.3 mg/dL without proteinuria. Follow-up PRA test levels were 0%, 75% for class I and II. Current therapies have had considerable success in reversing mixed, acute humoral and cellular rejection since it is being identified quickly and treated aggressively. The best use of rituximab to treat AMR should be evaluated in controlled trials using dosing strategies that include longer courses or retreatment schedules.

Keywords: Transplantation; Graft rejection; Rituximab; Plasmapheresis


Fig. 1
Clinical course; MPDS pulse, 250 mg iv bid for 3days; plasmapheresis, 1 plasma volume, 5% albumin replacement solution, COBE® Spectra Apheresis System; Rituximab 200 mg/body single infusion. Abbreviations: CsA, cyclosporine; MMF, mycophenolate mofetil; PDS, prednisone; Bx., biopsy; MPDS, methyl prednisolone; PP/IVIG, plasmapheresis with intravenous immune globulin.
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Fig. 2
Light microscopically, there was mild to moderate intimal arteritis (PAS stain, original magnification ×400)
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Fig. 3
Light microscopically, lymphocytes infiltration underneath the endothelium of large vessels is noted (PAS stain, original magnification ×400).
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Fig. 4
Immunofluorescent microscopically, there was diffuse staining for C4d in the peritubular capillaries(original magnification ×200).
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