Positive pre‐transplant flow‐panel reactive antibody detected after accelerated acute rejection with negative pre‐transplant flow crossmatch

Abstract:  A 30‐yr‐old woman underwent kidney transplantation from a flow cytometric lymphocyte crossmatch‐negative donor. Immunosuppression consisted of tacrolimus, mycophenolate mofetil, basiliximab and three days of steroid. On day 5 post‐transplant, she developed acute rejection and underwent anti‐rejection therapy consisting of steroid pulse and deoxyspurgualin. Retrospective analyses of anti‐human leukocyte antigen antibody revealed high flow panel reactive antibody (PRA) in the pre‐transplant serum without donor specific antibody (DSA) and positive DSA at the time of rejection. Anti‐rejection therapy was successful in treating cellular rejection but her graft function further deteriorated after three months post‐transplant and graft biopsy revealed chronic allograft nephropathy with positive staining for C4d in peritubular capillary, suggesting the presence of chronic antibody‐mediated rejection. Pre‐transplant positive flow PRA without DSA may also be a risk for acute and chronic rejection.