1國軍高雄總醫院外科部泌尿外科; 2義大醫院外科部泌尿外科; 3義守大學醫學院醫學系
Hyperacute Antibody-Mediated Rejection with Graft Loss in Cadaveric Kidney Transplantation: A Case Report
Chien-Ming Lai1,2, Chiang-Ting Wang1, Hua-Pin Wang2, Victor C. Lin23
1Divisions of Urology, Department of Surgery, Kaohsiung Armed Force General Hospital, Kaohsiung, Taiwan
2Divisions of Urology, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
3School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
Rationale: For patients with end stage renal disease, kidney transplantation is considered the best treatment. Hyperacute antibody-mediated rejection (AMR) is rare under current pre-transplantation protocol but was still been reported. It would influence graft outcome and high chance of graft failure. Here we present a case with hyperacute AMR in cadaveric kidney transplantation.
Patient concerns: A 37-year-old male patient was admitted for kidney transplantation, and no pre-existing immunization was noted. Latest Panel Reactive Antibody (PRA) test was low and complement-dependent micro lymphocytotoxicity cross-match with donor was negative. The surgery of cadaveric renal transplantation was performed with cold ischemia estimated at 8 h 57 min and reperfusion time at 28 min. After vessel anastomosis, the graft kidney revealed cyanotic at first but turned to pink in 15 minutes. Well blood flow under Doppler scan was found after the procedure. The patient received regular immunosuppressant agents, including mycophenolate mofetil, tacrolimus, and prednisolone. However, anuria and renal failure persisted after transplantation. Daily blood flow of graft vessels was checked but anuria and renal failure noted. Hemodialysis was administrated for suspected delay graft function on postoperative day 1, and we also tried low dose dopamine to increase organ perfusion. On postoperative day 6 we performed kidney biopsy and pathology revealed hyperacute AMR on postoperative day 8. Double filtration plasma pheresis was arranged immediately. On postoperative day 9, no blood flow of graft kidney was detected, and graft kidney nephrectomy was done after well explanation to the patient. Pathology showed extensive coagulation necrosis with congestion, interstitial hemorrhage, and mixed inflammatory cell infiltration. Fibrinoid material thrombus formation within severe vessels, interstitial inflammation, tubulitis, glomerulitits, transmural arteritis with fibrinoid necrosis, and peritubular capillaritis were also present under microscopic finding. After graft loss, the patient has returned to regular hemodialysis.
Lessons: With normal PRA and negative result of cross-match, there is no appropriate preventation for hyperacute AMR. When anuria happened, the possibility of hyperacute rejection should be aware of.