Hyperacute Rejection in a Kidney Transplant With Negative Crossmatch: A Case Report

Area of Science:

• Nephrology
• Immunology
• Transplantation

Background:

• Hyperacute rejection (HAR) is a rare but severe complication following organ transplantation.
• Pre-transplant crossmatch tests are crucial for detecting antibodies against donor antigens to prevent HAR.
• Standard crossmatch methods may not always detect all clinically significant antibodies.

Observation:

• A kidney transplant recipient with negative complement-dependent cytotoxicity and flow cytometry crossmatch developed clinical signs of HAR minutes after reperfusion.
• Luminex technology identified anti-DQ donor-specific antibodies (DSA) with a high mean fluorescence intensity (11,000).
• Despite plasmapheresis and immunosuppression, the patient required graft nephrectomy due to HAR.

Findings:

• Donor-specific antibodies (DSA), specifically anti-DQ DSA detected by Luminex, can cause hyperacute rejection even when conventional crossmatch tests are negative.
• Solid-phase assays like Luminex offer enhanced sensitivity for detecting clinically relevant DSA.
• The presence of anti-major histocompatibility complex class I-related chain A and anti-endothelial antibodies was ruled out in this case.

Implications:

• This case underscores the importance of utilizing sensitive solid-phase assays for DSA detection in kidney transplantation.
• It emphasizes that negative standard crossmatches do not entirely exclude the risk of HAR, especially in the presence of specific DSA.
• Clinical protocols may need re-evaluation to incorporate advanced antibody detection methods to mitigate HAR risk.