Case Studies

 Case 8.1 Acute rejection

An 18-year-old student with end-stage renal failure due to chronic glomerulonephritis was given a cadaveric kidney transplant. He had been on maintenance haemodialysis for 2 months, and on antihypertensive therapy for several years. His major blood group was A and his tissue type was HLA-A1, -A9, -B8, -B40, -Cw1, -Cw3, -DR3, -DR7. The donor kidney was also blood group A and was matched for one DR antigen and four of six ABC antigens. He was given triple immunosuppressive therapy with cyclosporin A, azathioprine and prednisolone.

He passed 5 litres of urine on the second postoperative day and his urea and creatinine fell appreciably. However, on the seventh postoperative day, his graft became slightly tender, his serum creatinine increased and he had a mild pyrexia (37.8°C). A clinical diagnosis of acute rejection was confirmed by a finding of lymphocytic infiltration of the renal cortex on fine-needle aspiration. A 3-day course of intravenous methylprednisolone was started. Twenty-four hours later his creatinine had fallen and urine volume increased.

Subsequently, the patient had similar rejection episodes 5 and 7 weeks postoperatively. Both were treated with intravenous corticosteroids, and he has since remained well for over 3 years. Cyclosporin A was discontinued after 9 months but he still takes a daily maintenance dose of immunosuppressive drugs, namely 5mg prednisolone and 50mg azathioprine.