Repository for Antibody Incompatible Transplantation Evidence

Misidentification of preformed anti-HLA-DP antibodies leads to antibody-mediated kidney transplant rejection: a case report.

BMC Nephrol. 2022 May 17;23(1):187 doi: 10.1186/s12882-022-02807-6.
Abstract
BACKGROUND:

Patients who are HLA-sensitized are at high risk for early antibody-mediated rejection (AMR) and worse outcomes. Therefore, it is crucial to detect the presence of donor-specific antibodies (DSAs) using pretransplant antibody identification and crossmatch assays. An error in antibody identification can lead to disastrous clinical outcomes. We present a case of acute AMR associated with preformed HLA-DPα and HLA-DPβ DSAs that were not identified before transplantation.

CASE PRESENTATION:

A 27-year-old woman received a second kidney transplant from a deceased donor. Her pretransplant panel-reactive antibody level was 94%. The complement-dependent cytotoxicity crossmatch was negative for T and B cells at the time of transplantation. She experienced early acute AMR proven by a kidney biopsy. Single antigen bead testing of the patient's serum at the time of rejection as well as the pre-second transplant serum revealed strong antibodies against the DPA1*01:03 and DPB1*02:01 alleles in the second donor. These antibodies were not identified by phenotypic bead assay during the patient's time on the waiting list. The patient was treated with plasmapheresis and anti-thymocyte globulin. However, she experienced abdominal pain on day 37 post-transplantation. Surgical exploration revealed a laceration on the transplanted kidney, which was then repaired. Subsequently, infected hematoma was suspected and the transplanted kidney was removed.

CONCLUSION:

The present case highlights the clinical significance of preformed HLA-DPα and HLA-DPβ DSAs. Accuracy in determination of HLA antibodies before transplantattion is critical for transplant outcome. HLA-DP typing and single antigen bead testing are recommended for a precise antibody interpretation, especially in highly sensitized patients. Careful interpretation of antibody testing results is essential for the success of organ transplantation.

Metadata
LEVEL OF EVIDENCE: Case Report
LANGUAGE: English
ORGAN TYPE: Kidney
KEYWORDS: Antibody-mediated rejection; Case report; Donor-specific antibody; HLA-DP; Kidney transplantation
MESH HEADINGS: Adult; Antibodies; Antilymphocyte Serum; Female; Graft Rejection; HLA Antigens; Histocompatibility Testing; Humans; Kidney Transplantation*; Kidney Transplantation / adverse effects; Tissue Donors