P115

Aim To present a highly sensitized patient with end stage renal disease who received his third kidney transplant from HLA-A, -B, -DR zero mismatched (0 MM) deceased donor (DD) and developed early acute cellular rejection (ACR – BANFF 2A) in absence of DSA. Methods Donor and recipient were HLA typed by RSSOP Luminex assay for HLA loci A, B and C, DRB1, DRB3/4/5, DQB1, DQA1, DPB1, and DPA1. HLA antibody identification were performed with One Lambda Luminex single antigen bead assay. Sera were tested untreated, treated with heat inactivation (HI) and 1:8 dilutions. CDC (with and without HI) and flow XM for T and B cells were tested at the day of transplant. Results A 40 years old man, highly sensitized (CPRA 100%) with a history of two previous renal transplants (lost due to non-immunological cause) with multiple class II DP antibodies with high MFI. The patient received a local zero mismatched donor was offered and with confirmatory testing an antigen level match for all HLA including DP. CDC and flow XM for T and B cells were negative. No DSA was detected pre or post-transplant. In post-operative day 1, the patient presented with anuria and hyperkalemia that mandated dialysis, and underwent dialysis throughout the rest of hospitalization as needed. Due to delayed graft function, he had a biopsy on post-operative day 8 that showed ACR – BANFF 2A – with negative C4d, peritubular capillaritis, and DSA. Treatment with anti-thymo globulin (ATG) did not show improvement. Consequently the patient received 3 sessions of plasmapheresis plus IvIG but the patient remained dialysis dependent. In post-operative day 50, biopsy showed chronic active T cell mediated rejection with no DSA. The graft remained non-functioning and graft nephrectomy was performed. This case suggests that highly sensitized kidney transplant candidates are at increased risk of cell mediated rejection and graft loss even in the context of 0 MM, negative DSA and flow crossmatch.