non-human leukocyte antigen (non-hla) antibodies in a kidney transplant recipient: a case report

Kidney transplantation is a treatment option for end-stage chronic kidney failure, with success highly dependent on immunoscreening to minimize rejection risks. transplant rejection can result from antibody-mediated or cellular immune responses. acute rejection is commonly associated with donor-specific anti-human leukocyte antigen antibodies (hla-dsa) but can also occur without hla-dsa. a 63-year-old male undergoing routine hemodialysis in preparation for a kidney transplant presented with anemia, a coombs test of +2, low estimated glomerular filtration rate (egfr), decreased c3 levels, and elevated potassium, creatinine, and urea. immunoscreening showed an hla match score of 3/16, a negative virtual cross-match, and 0% calculated panel reactive antibody (cpra). however, complement-dependent cytotoxicity (cdc) cross-match revealed 36%-40% lysis in t lymphocytes and 24%-35% in b lymphocytes. anti-nuclear antibody immunofluorescence (ana if) showed a fine-speckled nuclear pattern (1:80), while all tested autoantibodies were negative. cdc auto-cross-match was also positive in both b and t lymphocytes. these findings suggest antibody reactivity against donor cells, likely due to non-hla antibodies. such antibodies can increase the risk of hyperacute rejection by 30%-40%, emphasizing the need for additional perioperative management, including desensitization therapy (plasmapheresis, intravenous immunoglobulin, or rituximab) and post-transplant antibody monitoring. further evaluations, such as advanced autoantibody panels and endothelial cell cross-matching, are crucial to assess and mitigate rejection risks.