A high degree of sensitization to human leukocyte antigen requires more intensive induction therapy; however, this increases vulnerability to opportunistic infections following kidney transplantation. Although recent studies have suggested that combined induction therapy with antithymocyte globulin and rituximab would be more effective in highly sensitized kidney recipients, we experienced a case of near-fatal invasive pulmonary aspergillosis 2 months after combined induction and early

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... therapy for graft dysfunction. Fortunately, the patient recovered with intensive antifungal treatment and lung lobectomy for a necrotic cavity. Antifungal prophylaxis should be considered in cases undergoing intensive induction therapy. , et al: IPA after Combined Induction for KTP months after combined induction therapy using rituximab and antithymocyte globulin, in addition to early rejection therapy for graft dysfunction soon after deceased donor KTP. The patient recovered with intensive antifungal treatment and lung lobectomy for a necrotic cavity, and had good allograft function without intermittent hemodialysis. CASE REPORT A 57-year-old woman with diabetes mellitus and endstage renal disease had been on peritoneal dialysis for 4 years, and was changed to intermittent hemodialysis 1 year prior to surgery. She underwent deceased donor KTP with combination induction therapy using rituximab (300 mg/m 2 ) and antithymocyte globulin (1.5 mg/kg/day for 4 days) because of high-grade sensitization to HLA (PRA titer: class I 22%, class II 51%); she was given tacrolimus, mycophenolate mofetil, and prednisolone for immunosuppression. Four days after KTP, she developed an edematous left leg; acute deep vein thrombosis was diagnosed by Doppler ultrasonography; enoxaparin and anticoagulation therapy were started, and an inferior vena cava filter was inserted. Five days after KTP, her urine output decreased to less than 20 mL/hr; her creatinine (Cr) increased from 7.18 to 7.9 and her tacrolimus level was 4.4 ng/mL. She then developed generalized edema. Kidney color Doppler ultrasonography revealed a slightly increased segmental arterial resistive index in the renal allograft (resistive index, 1). For this reason, we could not perform an immediate allograft biopsy. Without biopsy-proven acute antibody-mediated rejection (AMR), even in the absence of donor-specific antibodies (DSA) in a highly sensitized patient with an expected high incidence of early AMR, we started intravenous methylprednisolone (500 mg daily for 3 days), in addition to plasmapheresis and 3 doses of low-dose immunoglobulin (100 mg/kg body weight). Allograft function gradually improved, but allograft biopsy performed 3 weeks after KTP diagnosed calcineurin inhibitor toxicity, rather than rejection. Discharge Cr was 1.4 mg/dL; because of leukopenia (white blood cell [WBC] count 1,500/L, absolute neutrophil count 1,155), low-dose immunosuppressive agents were given, including tacrolimus (7 mg/day), sirolimus (1 mg/day), and prednisolone (10 mg), but not mycophenolate