J Korean Soc Transplant.  2010 Mar;24(1):30-34. 10.4285/jkstn.2010.24.1.30.

Combination Treatment of Rituximab and Plasmapheresis in Acute Cellular Rejection with Focal Segmental Glomerular Sclerosis after Renal Transplantation

• Jeon JM
• Oh JS
• Kim SM
• Son YG
• Park YK
• Sin YH
• Kim JK
• Kim YJ

• KMID: 2202221
• DOI: http://doi.org/10.4285/jkstn.2010.24.1.30

Abstract

Focal segmental glomerular sclerosis (FSGS) accounts for recurrence in 20% to 40% of the renal allografts after transplantation, and it causes graft loss in 13% to 20% of the cases. We report here on successfully treating acute cellular rejection (ACR) combined with FSGS after a kidney transplantation with a combination treatment of plasmapheresis, rituximab and steroid pulse therapy. A 53-year-old female patient whose primary kidney disease was unknown developed massive proteinuria after living donor kidney transplantation. A urine protein/creatinine ratio of 13.42 and an elevated serum creatinine level was detected on postoperative days (POD) 10 and a renal biopsy showed acute cellular rejection (Banff IIb) combined with FSGS. We started steroid pulse therapy on POD 11. She underwent 5 plasmapheresis sessions in the first 3 week after transplantation and she received one dose of rituximab (375 mg/m2) on POD 12. The proteinuria decreased below the nephrotic range at POD 20 and the serum creatinine level was normalized. Three months later, the proteinuria was at 35 mg/day with stable graft function. Rituximab and plasmapheresis is a possible option to treat FSGS combined with a relapse of proteinuria after renal transplantation.

Keyword

FSGS; Rituximab; Kidney transplantation

MeSH Terms

Antibodies, Monoclonal, Murine-Derived
Biopsy
Creatinine
Female
Humans
Kidney Diseases
Kidney Transplantation
Living Donors
Middle Aged
Plasmapheresis
Proteinuria
Recurrence
Rejection (Psychology)
Rituximab
Sclerosis
Transplantation, Homologous
Transplants
Antibodies, Monoclonal, Murine-Derived
Creatinine

Figure

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  Fig. 1. Clinical course 1. Abbreviations: POD, postoperative days; BUN, blood urea nitrogen; UP, urine protein; KTP, kidney transplantation.

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  Fig. 2. Light microscopically, lymphocytic infiltration in glomerular capillary lumina is seen. Lymphocytes infiltrate along the edematous interstitium. Lymphocytic tubulitis is not present. PAS, ×200.

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  Fig. 3. On left, medium sized artery has subendothelial lymphocytic infiltration. The glomerulus shows focal mild mesangial widening. PAS, ×200.

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  Fig. 4. Electron microscopically, most foot processes are fused with microvilli formation. ×5,000.

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  Fig. 5. Glomerular lumina are infiltrated by lymphocytes. Endothelial cells are swollen. ×500.

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  Fig. 6. Clinical course 2. Abbreviations: POD, postoperative days; MPDS, methylprednisolone pulsing.

Reference

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