CEN Case Reports

, Volume 7, Issue 2, pp 288–291 | Cite as

Development of antibody mediated rejection shortly after acute cellular rejection in a pediatric kidney transplantation recipient

  • Mari OkadaEmail author
  • Koichi Kamei
  • Kentaro Matsuoka
  • Shuichi Ito
Case Report


Acute rejection is a major cause of graft loss in patients with kidney transplantations. However, the appropriate timing for performing a biopsy is often difficult to gauge in a clinical settings. We encountered an 8-year-old boy in whom antibody mediated rejection (AMR) associated with de novo donor-specific antibody (DSA) developed shortly after an episode of type IA acute cellular rejection (ACR). He had received a preemptive ABO-compatible kidney transplantation due to bilateral renal hypoplasia. Type IA ACR developed 2 months after transplantation and was successfully treated with methylprednisolone pulse therapy (MPT) and gusperimus hydrochloride. However, 4 months after transplantation, his serum creatinine level increased again. We decided to perform an additional biopsy despite having done the previous biopsy only a short time ago. Marked infiltration of inflammation cells in the peritubular capillaries (PTCs) with positive C4d staining was observed. AMR associated with de novo DSA with type IB ACR was newly diagnosed because DSA was not detected and the crossmatch test was negative before transplantation. He immediately received two courses of plasma exchange (PE), three courses of MPT, and rituximab. He confessed to non-adherence and underwent a patient education program with his family again. To date, no cases of AMR associated with de novo DSA shortly after ACR have been reported. Our experience lends support to the ‘episode biopsy’ method in which a biopsy is performed for each episode of serum creatinine increase as recommended by The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Working Group.


Kidney transplantation Antibody mediated rejection De novo donor-specific antibody 



The authors thank Dr. J. Tang from the Department of Education for Clinical Research, National Center for Child Health and Development, for his assistance with editing the manuscript.

Compliance with ethical standards

Human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from the patient included in this article.


  1. 1.
    Heilman RL, Nijim A, Desmarteau YM, Khamash H, Pando MJ, Smith ML, Chakkera HA, Huskey J, Valdez R, Reddy KS. De novo donor-specific human leukocyte antigen antibodies early after kidney transplantation. Transplantation. 2014;98:1310–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Devos JM, Patel SJ, Burns KM, Dilloglou S, Gaber LV, Knight RJ, Daber AO, Land GA. De novo donor specific antibodies and patient outcomes in renal transplantation. Clin Transpl.2011: 351–8.Google Scholar
  3. 3.
    de Kort H, Willcombe M, Brookes P, Dominy KM, Santoz-Nunez E, Galliford JW, Chan K, Taube D, McLean AG, Cook HT, Roufosse C. Microcirculation inflammation associates with outcome in renal transplant patients with de novo donor-specific antibodies. Am J Transpl. 2013;13:485–92.CrossRefGoogle Scholar
  4. 4.
    Ginevri F, Nocera A, Comoli P, Innocente A, Cioni M, Parodi A, Fontana I, Magnasco A, Nocco A, Taglimacco A, Sementa A, Ceriolo P, Ghio L, Zecca M, Cardillo M, Garibotto G, Ghiggeri GM, Poli F. Posttransplant de novo Donor-specific antibodies identify pediatric kidney recipients at risk for late antibody-mediated rejection. Am J Transpl. 2012;12:3355–62.CrossRefGoogle Scholar
  5. 5.
    Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transpl. 2009; 29(Suppl 3):S1–S155.Google Scholar
  6. 6.
    Wiebe C, Gibson IW, Blydt-Hansen TD, karpinski M, Ho J, Storsley LJ, Goldberg A, Birk PE, Rush DN, Nickerson PW. Evolution and clinical pathologic correlation of de novo donor-specific HLA antibody post kidney transplant. Am J Transpl. 2012;12:1157–67.CrossRefGoogle Scholar
  7. 7.
    Lefaucheur C, Loupy A, Vernerey D, Duong-Van-Huyen JP, Suberbielle C, Anglicheau D, Verine J, Beuscart T, Nochy D, Bruneval P, Charron D, Delahpusse M, Empana JP, Hill GS, Goltz D, Legendre C, Jouven X. Antibody-mediated vascular rejection of kidney allografts: a population-based study. Lancet. 2013;381:313–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Sawinski D, Forde KA, Trofe-Clark J, Patel P, Olivera B, Goral S, Bloom RD. Persistent BK viremia does not increase intermediate-term graft loss but is associated with de novo donor specific antibodies. J Am Soc Nephrol. 2015;26:966–75.CrossRefPubMedGoogle Scholar
  9. 9.
    Everly MJ, Everly JJ, Arend LJ, Brailey P, Susskind B, Govil A, Rike A, Roy-Chaudhury P, Moqilishetty G, Alloway RR, Tevar A, Woodle ES. Reducing de novo donor-specific antibody levels during acute rejection diminishes renal allograft loss. Am J Transpl. 2009;9:1063–71.CrossRefGoogle Scholar
  10. 10.
    Genberg H, Hansson A, Wernerson A, Wennberg L, Tydén G. Pharmacodynamics of rituximab in kidney transplantation. Transplantation. 2007;84(12 Suppl):S33–S36.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Nephrology 2018

Authors and Affiliations

  1. 1.Department of PediatricsMusashino Red Cross HospitalMusashinoJapan
  2. 2.Division of Nephrology and RheumatologyNational Center for Child Health and DevelopmentTokyoJapan
  3. 3.Division of PathologyDokkyo Medical University Koshigaya HospitalKoshigayaJapan
  4. 4.Department of Pediatrics, Graduate School of MedicineYokohama City UniversityYokohamaJapan

Personalised recommendations