Nephrol Dial Transplant (2010) 25: 307–310
doi: 10.1093/ndt/gfp526
Advance Access publication 20 October 2009
Exceptional Case
Antibody-mediated rejection following transplantation from
an HLA-identical sibling
Carrie A. Grafft1 , Lynn D. Cornell2 , James M. Gloor1,3 , Fernando G. Cosio1,3 , Manish J. Gandhi4 ,
Patrick G. Dean3,5 , Mark D. Stegall3,5 and Hatem Amer1,3
1
Division of Nephrology and Hypertension, Department of Internal Medicine, 2 Division of Anatomic Pathology, 3 William J von
Liebig Transplant Center; Mayo Clinic, 4 Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology and
5
Division of Transplantation Surgery, Department of Surgery, Rochester, MN, USA
Correspondence and offprint requests to: Hatem Amer; E-mail: [email protected]
Abstract
Putative antibody-mediated rejection (AMR) in HLAidentical sibling transplantation has rarely been reported
and occurred before routine calcineurin inhibitor use. A
29-year-old male developed allograft dysfunction following an HLA-identical renal transplant from his sibling.
A pretransplant panel-reactive antibody (PRA) was elevated, pre-transplant crossmatch was negative and no donorspecific antibody (DSA) was identified. Induction with
alemtuzumab was followed by maintenance immunosuppression with corticosteroids, tacrolimus and mycophenolate. A biopsy for allograft dysfunction suggested AMR,
but DSA could not be detected. Treatment for rejection
was transiently successful. Undetectable minor histocompatibility antibodies may have contributed.
Keywords: acute allograft dysfunction; alemtuzumab; limitations of
testing; living kidney donor; minor histocompatibility antigens
Introduction
Transplants from HLA-identical siblings usually result in
favourable outcomes [1]. We present a case of allograft
failure attributed to antibody-mediated rejection (AMR)
following transplantation from an HLA-identical sibling.
Although the allograft pathology was consistent with AMR,
no donor-specific antibody (DSA) was identified. The patient in this case received his transplant and much of his care
at another medical centre but was referred to our institution
due to persistent allograft dysfunction.
Case
A 29-year-old man with a history of an undefined renal disease who had progressed over 10 years to endstage disease received a kidney from his sister, an ABO-
compatible, HLA-identical sibling. Prior to transplant, the
panel-reactive antibody (PRA) was 95% for HLA class I
and 14% for class II, B- and T-cell flow cytometric crossmatch testing was negative and DSA was undetectable. He
received a standard dose immunosuppression regimen consisting of intraoperative alemtuzumab followed by corticosteroids, tacrolimus and mycophenolate sodium for maintenance. Five years before, he received a transplant from his
mother that failed within 1 year, reportedly due to Banff
type III acute rejection. No mention of a DSA or positive
C4d staining in the allograft at that time was in the records
that were available to us.
Although the patient felt well after transplant and did
not need dialysis, his renal function did not improve as
quickly as expected. On post-operative Day 7, his creatinine
was 2.4 mg/dl. A biopsy was performed and surprisingly
showed marginated mononuclear cells and neutrophils in
peritubular and glomerular capillaries, acute tubular injury
and diffuse, bright staining of peritubular capillaries for C4d
by immunofluorescence (Figure 1). Repeat flow cytometric
T- and B-cell crossmatch testing was found to be positive.
The findings were consistent with AMR.
Initial treatment for AMR consisted of pulse methylprednisolone, five sessions of plasmapheresis followed by
10 mg/kg intravenous immunoglobulin (IVIG) (Days 9–
11) and two doses of rituximab (Days 13 and 30). A repeat biopsy (Day 38) demonstrated mild improvement. Persistent C4d staining prompted the administration of two
treatments with 2 g/kg IVIG (Days 45–46). A biopsy performed 10 weeks following transplantation was again compatible with AMR, leading to rituximab treatment and repeat plasmapheresis and IVIG (2 g/kg). Additionally, oral
cyclophosphamide replaced mycophenolate sodium.
Two months later, his renal function continued to be poor
(creatinine 3.0 mg/dl). The repeat biopsy suggested persistent AMR. This puzzling situation prompted his transfer to our hospital for management. The biopsy findings
were unchanged. Cyclophosphamide was replaced with mycophenolate mofetil because of leucopaenia. We confirmed
C The Author 2009. Published by Oxford University Press [on behalf of ERA-EDTA]. All rights reserved.
For Permissions, please e-mail: [email protected]
308
C. A. Grafft et al.
Fig. 1. The kidney biopsy at 1 week post-transplant showed features of antibody-mediated rejection: glomerulitis with infiltrating mononuclear cells
and neutrophils [upper right panel, periodic acid-Schiff (PAS) stain], peritubular capillaritis [upper left panel, haematoxylin and eosin (H&E) stain]
and diffuse, bright staining of peritubular capillaries for C4d by immunofluorescence (inset). By electron microscopy, both glomerular and peritubular
capillary endothelial cells showed reactive changes, with enlargement of the cells, loss of fenestrations and areas of microvillous transformation (lower
panels).
that the donor and recipient were matched at HLA-DP, DQ
and C loci, and high resolution typing did not demonstrate
any discrepancy. The referring institution had arranged
for testing for antibodies against phospholipids, the angiotensin receptor, vimentin, red blood cell antigens and
random platelet antigens were negative. Testing for antibodies against major-histocompatibility-complex class Irelated chain A (MICA) was borderline positive but not
donor specific. Monocyte crossmatch performed by another
medical centre was reported as inconclusive.
The patient was ultimately dismissed from our hospital with improved and stable allograft function (creatinine
2.1 mg/dl) and on standard dose immunosuppression regimen with tacrolimus, mycophenolate mofetil and prednisone. His primary transplant nephrologist resumed care
and his immunosuppressive regimen remained the same.
Unfortunately, within 3 months, his creatinine increased
to 6.7 mg/dl. Histologic evidence of AMR with borderline changes for cellular rejection with patchy interstitial inflammation was demonstrated, but DSA was never
detected. He was again treated for AMR, but ultimately
maintenance dialysis was needed. Before immunosuppression was tapered, a biopsy was done and revealed severe
changes of AMR, with arterial fibrinoid necrosis, diffuse and global mesangiolysis, glomerular and peritubular
capillary neutrophils and mononuclear cells. Immunofluorescence demonstrated bright, diffuse C4d staining
(Figure 2).
Discussion
Renal transplantation from an HLA-identical sibling donor
usually results in favourable long-term outcomes [1]. Our
patient had an HLA-identical sibling donor, but developed
AMR soon after transplant. According to the Banff ‘07
schema, definitive diagnosis of acute AMR requires histologic features of tissue injury, immunopathologic evidence
of antibody (e.g. C4d positivity) and serologic evidence of
DSA [2]. Banff criteria for AMR were not met in this case
Antibody-mediated rejection following transplantation from an HLA-identical sibling
Fig. 2. A kidney biopsy (H&E) at 8 months post-transplant showed severe
changes of AMR, with marked subendothelial oedema, haemorrhage, and
fibrinoid necrosis in arteries, global mesangiolysis, glomerular and peritubular capillary neutrophils and mononuclear cells and bright, diffuse
C4d staining by immunofluorescence (inset). There was no evidence of
transplant glomerulopathy.
despite clear histologic evidence because of undetectable
DSA.
Although the patient had a positive flow crossmatch early
post-transplant, the recent exposure to alemtuzumab may
have complicated the result. Alemtuzumab is a humanized
monoclonal antibody to CD52, an antigen very specific to
lymphocytes, monocytes, eosinophils and epithelial cells
of the epididymis and seminal vesicle [3]. Alemtuzumab
can be recognized as an anti-human antibody and has resulted in false positive cross matches by flow cytometric
and complement-dependent cytotoxic techniques [4].
C4d, a marker of antibody-mediated complement fixation on renal endothelium, was demonstrated on all biopsies
in this case. In humans, C4d disappearance from peritubular capillaries has occurred as soon as 8 days following
antibody removal [5]. The sensitivity and specificity of
peritubular C4d staining for AMR is 95% and 96%, respectively, when serum DSA is used as a rejection criterion [5].
Serologic detection of unusual, non-HLA DSA leading to
rejection is limited. As such, this case highlights the limitations of the existing diagnostic criteria for acute AMR.
With recent advances in DSA characterization, MICA
antigens, minor histocompatibility antigens (mHA), endothelial cell (EC) antigens and other host-specific antigens
have been studied in rejection, but their significance is not
well defined. Presensitization with anti-MICA antibodies
has been associated with decreased allograft survival [6].
Interestingly, traditional crossmatching techniques are insensitive when MICA antibodies are present because the
antigens are not present on peripheral lymphocytes [6].
HLA-identical siblings usually have matched MICA because of the chromosomal location of MICA, and therefore
rejection resulting from these antibodies in HLA-identical
sibling organ transplantation is unlikely. Tests for MICA
antibodies were borderline positive in this patient but not
donor specific.
309
DSA is sometimes not initially identified because testing for antibodies against HLA-DP, DQ and C loci is not
routinely performed. These antibodies do not often result in
rejection, but it has been reported [7]. In true HLA-identical
kidney transplant this should not be a cause. Additionally,
the level of antibody may be too low for detection or is
absorbed in the allograft and only identified when an allograft nephrectomy is performed [8]. The patient in this case
did not have an allograft nephrectomy. We also do not have
tissue or serum from the time of his first kidney transplant
to look for DSA. Another possibility is the presence of an
antibody that we do not have a ligand to.
In HLA-identical sibling organ transplantation, graft rejection more often occurs when recipients have increased
parity, prior blood transfusions or previous transplants. Furthermore, these transplants fail more frequently among recipients who have a high PRA suggesting that antibodies against mHA may contribute to rejection [9]. If only
HLA-reactive antibodies were important, the PRA would
be irrelevant in these transplants. Antibodies to mHA or
EC may occur together with anti-HLA resulting in rejection [9]. Interestingly, the recipient in this case had a high
PRA.
Putative AMR in HLA-identical sibling transplantation
has rarely been reported and occurred before calcineurin
inhibitor use. Collins et al. found diffusely positive C4d
staining of peritubular capillaries with evidence of tissue
injury in 2 of 17 HLA-identical grafts (HLA-A, -B and -C
loci) [10]. Serologic analysis was unavailable, but mixed
lymphocyte reaction was nonreactive pre transplant.
This case highlights several points. Antibody-mediated
damage occurs in HLA-identical sibling organ transplantation receiving a calcineurin inhibitor. The responsible antibodies are presumably against non-HLA antigens and were
not detected. Because a subset of DSA is not necessarily
detected by current techniques, clinicians should consider
AMR if the renal pathology is suggestive even if DSA
is not detected. Lastly, false-positive crossmatch testing
is possible after using chimeric or humanized monoclonal
antibodies.
Conflict of interest statement. None declared.
References
1. Shimmura H, Tanabe K, Ishida H et al. Long-term results of living kidney transplantation from HLA-identical sibling donors under
calcineurin inhibitor immunosuppression. Int J Urol 2006; 13: 502–
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2. Solez K, Colvin RB, Racusen LC et al. Banff 07 classification of renal
allograft pathology: updates and future directions. Am J Transplant
2008; 8: 753–760
3. Hale G. Alemtuzumab in stem cell transplantation. Med Oncol 2002;
19(Suppl): S33–S47
4. Book BK, Agarwal A, Milgrom AB et al. New crossmatch technique
eliminates interference by humanized and chimeric monoclonal antibodies. Transplant Proc 2005; 37: 640–642
5. Nickeleit V, Zeiler M, Gudat F et al. Detection of the complement
degradation product C4d in renal allografts: diagnostic and therapeutic
implications. J Am Soc Nephrol 2002; 13: 242–251
6. Zou Y, Stastny P, Susal C et al. Antibodies against MICA antigens and
kidney-transplant rejection. N Engl J Med 2007; 357: 1293–1300
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7. Vaidya S, Hilson B, Sheldon S et al. DP reactive antibody in a zero
mismatch renal transplant pair. Hum Immunol 2007; 68: 947–949
8. Proust B, Kennel A, Ladriere M et al. Unexpected anti-HLA-DR and DQ alloantibodies after nephrectomy of an HLA-DR and -DQ identical
first renal transplant. Transpl Immunol 2009; 21: 166–168
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9. Opelz G. Non-HLA transplantation immunity revealed by lymphocytotoxic antibodies. Lancet 2005; 365: 1570–1576
10.Collins AB, Chicano SL, Cornell LD et al. Putative antibody-mediated
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Received for publication: 31.3.09; Accepted in revised form: 14.9.09
Nephrol Dial Transplant (2010) 25: 310–313
doi: 10.1093/ndt/gfp527
Advance Access publication 9 October 2009
Acute antibody-mediated rejection after ABO-incompatible kidney
transplantation treated successfully with antigen-specific
immunoadsorption
Søren Andreas Just1 , Niels Marcussen2 , Ulrik Sprogøe1 , Pernille Koefoed-Nielsen3 and Claus Bistrup4
1
Department of Clinical Immunology, 2 Department of Pathology, Odense University Hospital, Odense, 3 Department of Clinical
Immunology, Aarhus University Hospital, Skejby and 4 Department of Nephrology, Odense University Hospital, Odense, Denmark
Correspondence and offprint requests to: Søren Andreas Just; E-mail: [email protected]
Abstract
ABO-incompatible kidney transplantation is possible after pre-treatment with rituximab, intravenous immunoglobulin and basiliximab combined with tacrolimus, mycophenolate mofetil and prednisolone. We report on the
first patient treated with this protocol who developed
acute antibody-mediated rejection (Banff grade II with
IgG deposits) caused by ABO antibodies (anti-B). Antirejection treatment with anti-B-specific immunoadsorption, intravenous immunoglobulin and methylprednisolone
efficiently cleared deposited IgG from the kidney allograft
and re-established normal kidney function. We suggest that
ABO-incompatible kidney transplantation complicated by
acute antibody-mediated rejection, caused by ABO antibodies, may successfully be treated with this regime.
Keywords: ABO-incompatible kidney transplantation; acute
antibody-mediated rejection; antigen-specific immunoadsorption
antibody removal such as immunoadsorption (IA), plasma
exchange or double filtration [2–4].
ABOi kidney transplantation in our department is performed in accordance with Tydén et al. [5]. The principals of
this protocol are (1) reduced immunoglobulin synthesis following anti-CD20 treatment (rituximab), (2) pre-transplant
removal of ABO blood group antibodies by repeated ABO
antigen-specific IA, (3) induction therapy with IVIG and
(4) triple immunosuppression with tacrolimus, mycophenolate mofetil and prednisolone.
Probably due to the relatively limited experience with
this protocol, no ABO antibody-mediated rejection has, to
our knowledge, previously been published.
We report on a patient who 43 days after ABOi kidney transplantation developed aAMR, concomitant with
rising anti-B titre. This anti-B-mediated aAMR was successfully treated with repeated antigen-specific IA, highdose methylprednisolone and IVIG.
Case report
Introduction
Acute antibody-mediated rejection (aAMR) after ABOincompatible (ABOi) kidney transplantation caused by
ABO blood group antibodies is characterized by elevation
of the anti-A or anti-B titre combined with graft dysfunction
[1].
A standardized rescue treatment regime of aAMR after
ABOi transplantation has not been established. Treatment
protocols for aAMR typically comprises intravenous immunoglobulin (IVIG) in combination with modalities for
A 54-year-old Caucasian male with nephrosclerosis and
treated with peritoneal dialysis was transplanted with an
ABOi kidney (blood group B to O, HLA-A,B,-DR mismatch 2:1, no donor-specific HLA class I or II antibodies).
The patient was medically treated according to the Tydén
protocol [5]. However, on the day of rituximab treatment
(Day −42), the IgG anti-B titre had increased (1:512), and
24 h after the infusion, the patient developed sterile peritonitis. After 30 days, just before the first IA (glycosorb B), the
IgG anti-B titre was 1000 (Day −12) and after three IA’s
C The Author 2009. Published by Oxford University Press [on behalf of ERA-EDTA]. All rights reserved.
For Permissions, please e-mail: [email protected]