Abstract: FR-PO1153
Coexistence of Acute Cellular Allograft Rejection and Extrarenal Recurrence of p-ANCA Vasculitis After Kidney Transplantation
Session Information
- Transplantation: Clinical - Transplant Access, Recipient Evaluation, Living Donors, Pregnancy, and More
October 23, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Alsaedi, Zainulabdeen S., Washington University in St Louis, Saint Louis, Missouri, United States
- Gomide Almeida, Guilherme, Washington University in St Louis, Saint Louis, Missouri, United States
- Khan, Muhammad Ulusyar, Washington University in St Louis, Saint Louis, Missouri, United States
- Alrata, Louai, Washington University in St Louis, Saint Louis, Missouri, United States
- Messias, Nidia Cordeiro, Washington University in St Louis, Saint Louis, Missouri, United States
- Merzkani, Massini, Washington University in St Louis, Saint Louis, Missouri, United States
- Paul, Rohan Singh, Washington University in St Louis, Saint Louis, Missouri, United States
- Murakami, Naoka, Washington University in St Louis, Saint Louis, Missouri, United States
Introduction
We report a rare case of simultaneous acute cellular rejection (ACR) of a renal allograft and isolated pulmonary recurrence of P ANCA MPO associated vasculitis presenting as diffuse alveolar hemorrhage (DAH), without renal vasculitis on biopsy
Case Description
A 25 year old female with ESRD from biopsy proven ANCA associated crescentic GN who underwent DDKT before 4 years (0/6 HLA MM, KDPI 36%, cPRA 0%). She received rATG induction and was maintained on tacrolimus, azathioprine and prednisone, with persistently low P ANCA
She presented with severe non oliguric AKI after self discontinuing tacrolimus. She was markedly hypertensive; renal US showed no renal artery stenosis or obstruction. Labs are shown in the table
Allograft biopsy showed Banff IB TCMR with no recurrent ANCA vasculitis. She was treated with pulse steroids and rATG (3 mg/kg). After the first rATG dose, she developed hemoptysis and respiratory distress requiring ICU care. Imaging suggested pulmonary edema, but bronchoscopy confirmed DAH
Discussion
ANCA vasculitis recurrence usually involves the allograft. However, this case shows an unusual isolated pulmonary relapse occurring with TCMR. The onset soon after rATG suggests possible cytokine mediated reactivation. A high index of suspicion is required when vasculitis is absent on renal biopsy
Laboratory Findings
A. PAS: Normal glomerulus without crescents; tubules with severe tubulitis
B & C. H&E: Tubulointerstitial inflammation without vascular inflammation