CASE PRESENTATION DR SANJAY MAITRA, DR DENISH SAVALIA, NEPHROLOGY DEPARTMENT APOLLO HOSPITALS

CLINICAL HISTORY BACKGROUND HISTORY: Presenting a case of 29 yrs female mrs X, Admitted for Living Related Renal transplantation. BACKGROUND HISTORY: No history of any prolonged medical illness before pregnancy. During her 1st Pregnancy, no complain till 32 weeks of gestation. At 33 weeks, She developed Bleeding P/V , her blood pressure was 220/110 mmhg.serum creatinine was 3.2 mg/dl and underwent urgent LSCS.

After LSCS blood pressure became control and not on any antihypertensive medication. History of 2 unit blood transfusion during this period. After a Period of 1 week, her serum creatinine was 1.6mg/dl and on 2 antihypertensive medications.

USG abdomen showed one small kidney USG abdomen showed one small kidney.Biopsy was offered but family declined in term of risk. In Jan 2016, She presented with uremia and fluid overload with serum creatinine was 9 mg/dl and hemodialysis was initiated through rt ijv access in view of ESRD. She was on MHD through AVF 3 times/week. Patient remained severe hypertensive during HD with 5 antihypertensive medications. Intradialytic wt gain remained 2 kg.

DONOR STATUS Mother was donor. AGE : 58 years Blood group : O POSITIVE Non DM, Non HTN,Obese HLA cross match by DSA LUMINEX igG class I and II in 2 occasion 2 days before transplant : Negative HLA HAPLOTYPE : 50% matched

RECIPIENT STATUS Age : 29 years Blood gp : O positive HLA cross match by DSA LUMINEX both igG class I and II in 2 occasion 2 days before transplant : Negative HLA HAPLOTYPE : 50% matched Pre transplant immunosuppressant started 48 hrs before day of transplant including Tac,MMF,Prednisolone. Induction therapy : 2 doses of Basiliximab 20 mg on day 0 and day 4.

Patient underwent renal transplantation surgery on 10th feb 2017. The surgery remained uneventful. Post op period: Patient complained abdominal pain at surgical site, POD 3rd she had fever, loose motions, high blood pressure 200/100 mmhg on NTG infusion followed by oral antihypertensive medications.

Post op course of urine output and renal function Post op day Urine output per day Body weight (Kg) Serum creatinine(mg/dl) Day 0 20 L 60 6 Day 1 14 L 61 3 Day 2 8 L 61.8 1.3 Day 3 3 L 63 1.7 Day 4 850 mL 64.5 2 Day 5 275 mL 66.7 2.7 Day 6 50 mL 68 3.5

POD 4: Underwent transplant kidney doppler Transplant kidney doppler was done and showed absent diastolic flow in main renal artery and intrarenal branches, with resistive indices 1. POD 5: Underwent graft biopsy Graft biopsy peritubular capillaritis, C4d Positivity in 60-70% PTC. HLA cross match by DSA luminex was repeted and IgG class I 4652 MFI and class II was <500 MFI. DIAGNOSIS : Acute Antibody mediated rejection.

GRAFT BIOPSY

GRAFT BIOPSY

TREATMENT Plasma exchange : 5 cycles, 2L,2 hrs. Followed by IVIG : 10 gm/day for 7 doses. Alternate day hemodialysis. After 3rd cycle, urine output improved 600ml than 1 L than 2 L daily. Serum creatinine was improved to 1.3 mg/dl. RITUXIMAB : 500 mg in 500ml NS over 5 hrs.1 dose was given. After 5 days, CD 19 was done and it was <5.

We repeated DSA luminex IgG class I and class II both were negative. On discharge, urine output was 5 L / day and serum creatinine was 1.3 mg/dl and triple immunosuppressant(Tac + MMF + prednisolone). On follow up, serum creatinine was 0.9 mg/dl..

COURSE OF GRAFT FUNCTION Basiliximab , Methylpred Basiliximab (2nd dose ) Plasma Ex + IVIG ( 1st dose ) Plasma Ex + IVIG ( 3rd dose ) Rituximab

OUTCOME OF EARLY AMR In follow-up over 48 months from the time of transplantation, overall graft loss was 38 and 7 percent in those with and without C4d, respectively. C4d positivity was related to the presence of donor- specific antibodies (DSAs), and graft survival was markedly shorter in C4d-positive versus C4d- negative biopsies (50 percent graft survival of four versus eight years). Positive C4d staining was the strongest predictor of graft loss.

THANK YOU..!