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제목	Treatment of acute antibody-mediated rejection using a steroid pulse therapy in a renal tansplant patient: a case report.
저자	Joon-Hyuk Seo*
출판정보	2016; 2016(1):
키워드	Acute rejection, Renal transplantation, steroid pulse
초록	Background: Although the widespread use of potent and specific immunosuppressive agents have significantly reduced acute rejection rates and substantially improved 1-year graft survival following renal transplantation, long-term (10-year) survival rates have improved slow over the past decade. Recent studies show that antibody-mediated rejection (AMR) is among the most important barriers to improving long-term outcomes. Here we report the successful treatment of acute antibody-mediated rejection (AMR) with steroid pulse therapy. Methods: The patient, 50-year-old woman, underwent her first renal transplantation with a deceased donor kidney. The patient received Basiliximab (an IL-2-blocking agent) on the operative day and on the post-operative day 4, respectively. She took immunosuppressants including mycophenolate mofetil (MMF), tacolimus and glucocorticoid. Since post-transplant day 7, serum creatinine level abruptly increased by about 84 percent (from 1.21 mg/dl to 2.23 mg/dl) with a decrease of urine output in a day, the graft biopsy, on the post-transplant day 8, was performed and administration of glucocorticoid (methylprednisolone 250mg every 12 hours for 3 days, then 150mg every 12 hours for 3 days) was done in order. Results: Efficacy of steroid pulse therapy was obvious and prompt. Serum creatinine level, which was 2.23 mg/dL on the first day of steroid pulse therapy, decreased to 1.53 mg/dL on the third day of that. Meanwhile, the graft biopsy before steroid pulse therapy revealed minimal C4d-positivity (C4d1), moderate peritubular capillaritis (ptc2) and segmental glomerulitis (g2), which confirmed acute antibody-mediated rejection. After a steroid pulse therapy, an oral prednisolone was tapered rapidly to the same dose which the patient had been taking prior to the episode. We didn’t increase the dose of tacrolimus because the serum level of tacrolimus prior to the episode of acute rejection was in the therapeutic range of serum concentration of tacrolimus. We had her peak panel reactive antibody (PRA) result after the acute rejection episode. The PRA composition was 78% class I and 69% class II, but definite donor-specific antibody (DSA) was not detected. Conclusion: A steroid pulse therapy was administered as a rescue treatment for a patient who developed AMR without plasmapherese and a preemptive administration of intravenous immunoglobulin (IVIG) or rituximab. The efficacy of the treatment was remarkable.
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