ABO血型與人體白血球抗原配對一致活體腎移植超急性排斥 – 病例報告
陳柏華、陳俊吉、林介山、王百孚、江恆杰、陳建廷
彰化基督教醫院 外科部 泌尿科
Hyperacute rejection in a HLA and ABO compatible living donor transplant – a case report
Pao-Hwa Chen, Chun-Chi Chen, Jesen Lin, Bai-Fu Wang, Heng-Chieh Chiang, Jian-ting Chen
Divisions of Urology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
Introduction:
In the modern era of pre-transplant crossmatching tests, hyperacute rejection is very rare. Here, we present a case of living donor transplant with no mismatched in ABO or HLA typing.
Case presentation:
This 17 years old patient with initial presentation of blurred vision with elevated renal function and proteinuria and hematuria was admitted due to elevated renal function with proteinuria and hematuria. She was first admitted into Nephrology ward and renal biopsy showed hypertensive nephropathy. Due to her symptoms, peritoneal dialysis was suggested. Four months after diagnosis, her mother decided on donating her kidney to the daughter. After initial survey, blood work for ABO typying and HLA typing (HLA-A/B/C/DR/DQ genotype, HLA class I/II PRA) and cross-matching was done. The total operating time for donor nephrectomy was 3 hours with an warm ischemia time (time from transection of renal vessels to complete flushing of donor kidney) of 2 minutes 55 seconds. Total cold ischemia time (time from removed from donor to complete vessel anastomosis of receipiant) was 5 hours. There was no leakage around anastomosis site and perfusion was checked with doppler sono. Poor urine output (total of 20 cc of urine, from complete vessel anastomosis to wound closure) was noted and donor kidney is flaccid. Poor renal function along with decrease urine output prompt Nephrologist to ordered a Tc-99m-DTPA scan, which showed no renal function. Suspecting vessel thrombus, emergent endovascular thrombolysis was done. Even after pulse therapy and adequate immunosuppression, we were not able to regain her renal functions. With the continuing deteriorating renal function, receipiant nephrectomy was performed. Pathology showed clinical picture of hyperacute rejection.
Conclusion and discussion:
In our case, poor kidney function was noted after unclamping of vessels and persisted after the operation. Surgical technique and anastomosis was not the problem, but an unforseen immune response even after adequate crossmatching. The receipiant did had elevated percentage of HLA class I PRA, which might increase her chances of rejection. Low percentage of HLA PRA and good crossmatching have been related to low incident of hyperacuterejection. ABO incompatibility related rejection has decrease with pre-operative regimen of plasmaphoresis and immuno-suppresants. In cases of HLA and ABO compatible transplantation, acute rejection is very rare and hyperacute rejection is extremely rare.