Plasma Cell–Rich Rejection After Kidney Transplantation and the Role of Donor-Specific Antibodies: A Case Report and Review of the Literature

• We describe a case of plasma cell–rich rejection accompanied by antibody-mediated rejection.
• This is the 1st clinical review article about plasma cell–rich rejection.
• Some cases of plasma cell–rich rejection are associated with donor-specific antibodies.

ObjectiveWe report a case of the clinical course and pathologic findings for a kidney transplant recipient with plasma cell–rich rejection (PCRR) accompanied by antibody-mediated rejection (ABMR).MethodsA 29-year-old man with end-stage renal disease caused by lupus nephritis received an ABO-compatible living kidney transplant.ResultsEighteen months after transplantation, the patient presented with proteinuria and increased serum creatinine. An episode biopsy revealed severe tubulointerstitial infiltration with plasma cells accompanied by peritubular capillaritis and positive findings on immunofluorescent C4d staining. Donor-specific antibodies were positive for DR52, and the patient was subsequently diagnosed with PCRR accompanied by ABMR. Treatment was initiated with high-dose steroids, intravenous immunoglobulin, gusperimus hydrochloride, muronmonab antibody CD3, and rituximab. However, ABMR persisted and allograft failure developed 20 months after onset.ConclusionsWe argue that PCRR accompanied by ABMR is a subtype of PCRR that can progress to allograft failure owing to persistent ABMR.