Successful Treatment of Early Acute Antibody-mediated Rejection in an Human Leukocyte Antigen-incompatible and ABO-incompatible Living-donor Kidney Transplant Patient

For successful human leukocyte antigen-incompatible (HLAi) or ABO-incompatible (ABOi) living-donor kidney transplantations (LDKTs), pretransplant desensitization is essential; however, early antibody-mediated rejection (ABMR) remains the most important complication after HLAi or ABOi transplantation. Here, we report a case of early acute ABMR in simultaneous HLAi and ABOi LDKT with preformed donor-specific antibody (DSA), despite desensitization. Dialysis-dependent, severe ABMR occurred with a rebound of pre-existing DSA and appearance of de novo DSA after initial normalization of renal function, 8 days postoperatively. However, a low anti-ABO antibody titer (1:8) was maintained after transplantation. Combination therapy of plasmapheresis, high-dose intravenous immunoglobulin, and bortezomib improved both ABMR and renal functions. Thus, an appropriate preventive and therapeutic management for early ABMR is important among high-risk LDKT patients. Furthermore, early AMBR can occur despite pretransplant desensitization as seen in this case, and close monitoring of the patient and prompt management are considered vital for better therapeutic outcomes.