A 40-year-old woman was seen by her family physician after several episodes of painless hematuria.

Case 1

A 40-year-old woman was seen by her family physician after several episodes of painless hematuria. On direct questioning, she complained of worsening malaise and swelling of her legs and hands over the previous 2 weeks. She also reported that despite a high fluid intake, she was urinating much less frequently than normal. She had no significant medical history.

On examination, the patient was pale and had generalized swelling of her extremities. Her temperature was 38.5°C (101°F) and her blood pressure was 160/110 mm Hg. She had no palpable masses or hepatosplenomegaly.

A diagnosis of idiopathic and rapidly progressive glomerulonephritis was made. She was given antihypertensive agents, corticosteroids, and azathioprine for 2 weeks, but her renal function deteriorated, and end-stage renal failure was diagnosed. Hemodialysis was initiated.

In preparation for a possible renal transplant, she was tissue-typed for MHC antigens using anti-HLA antibodies. She was found to be HLA-A10, A28, B7, Bw52, Cw2, Cw6, DR2, DRw10, and blood group B positive. A suitable cadaveric kidney was found from a donor of HLA-A9, A28, B7, B17, Cw2, Cw6, DR2, DR4, and blood group B positive. A crossmatch of the patient’s serum with donor lymphocytes was satisfactory.

She underwent successful kidney transplantation. Her post transplantation treatment was a combined triple-immunosuppressive regimen of prednisolone, cyclosporine, and azathioprine. She progressed well immediately after transplantation.

Twelve days after engraftment, the patient developed a fever and was noted to be lethargic. Physical examination revealed generalized edema. Her blood pressure was 165/110 mm Hg. Her urine output had dropped significantly. A renal biopsy was performed. Histologic examination demonstrated significant interstitial mononuclear cell infiltration. This finding was consistent with the diagnosis of acute graft rejection.

She was immediately treated with parenteral methylprednisolone. This treatment failed to improve her renal function, and an antilymphocyte monoclonal antibody was administered. Her renal function improved, and she was eventually discharged receiving cyclosporine therapy.

Questions

1. What factors are important in matching donor to recipient in renal transplantation?

2. How does this patient’s graft rejection compare with other categories of graft rejection in human kidney transplantation?