Case reports in transplantationKidneyPrimary Graft Dysfunction After Zero-Mismatch Kidney Transplantation Secondary to Early Biopsy-Proven Acute Cell-Mediated Rejection: Case Report

•Zero-HLA-mismatch kidney transplants are associated with better graft outcomes and fewer immunologic adverse events.•UNOS gives priority to recipients with zero HLA mismatches.•Additional prioritization points are awarded on a sliding scale to highly sensitized recipients who have PRA ≥80% to offset their matching disadvantages.•This case report suggests that highly sensitized recipients might not benefit from the immunologic advantages of the zero-HLA-mismatch graft.

We report a case of primary renal allograft dysfunction and early acute cell-mediated rejection after a 12/12 HLA antigen zero-mismatch (0MM) transplant. The recipient was a 40-year-old white man who was highly allosensitized, with a calculated panel reactive antibody score of 100%. In posteroperative day 1 the recipient remained anuric and underwent dialysis because of hyperkalemia. Graft biopsy showed early acute cellular rejection, Banff grade 2B. No evidence of antibody-mediated rejection was observed. To our knowledge, this case is the 1st to report early cell-mediated rejection after 12/12 HLA antigen 0MM kidney transplantation. This case suggests that highly sensitized candidates are at high immunologic risk even in the context of 0MM kidney transplantation.