pISSN 2671-8790
eISSN 2671-8804


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J Korean Soc Transplant 2011; 25(2): 116-122

Published online June 30, 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

Departments of Internal Medicine1, General Surgery2, Bong Seng Memorial Hospital, Busan, Department of Pathology, Yeungnam University College of Medicine3, Daegu, Korea

Correspondence to: 신용훈, 부산시 동구 중앙대로 401(좌천동) 김원묵기념 봉생병원 신장내과, 601-723
Tel: 051-664-4220, Fax: 051-631-8054
E-mail: syhpmj@hanmail.net

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