Successful rescue of refractory acute antibody-mediated renal allograft rejection with splenectomy--a case report

Highly sensitized patients receive fewer kidney transplants and have a high risk for severe rejection with increased rates of graft loss. We present a highly sensitized child who after desensitization protocol received a kidney transplant and developed refractory acute antibody-mediated rejection. He failed to respond to standard therapy and needed an urgent splenectomy as rescue therapy. Our patient, an 18-yr-old AA male with ESRD due to obstructive uropathy received a second DD transplant. The allograft functioned immediately with SCr 1.4 mg/dL on day #5. On day #8, he was re-admitted with fever, oligoanuria, and renal failure. He was started on methylprednisolone pulse, thymoglobulin, intravenous immunoglobulin, and PP. The transplant kidney biopsy revealed features suggestive of acute AMR. On day #14, the patient remained dialysis dependent with no response to therapy. He underwent an urgent splenectomy and a slow increase in urine output and GFR was noted. The SCr one month post-splenectomy was 1.1 mg/dL. At one yr post-txp, his GFR remained stable with SCr 0.9 mg/dL on tacrolimus, mycophenolate mofetil, and prednisone. Urgent splenectomy successfully reversed refractory acute AMR, in our highly sensitized patient with second renal transplant.