• Yao-Yu Tsai, Lee-Moay Lim, Hung-Tien Kuo, and Yi-Chun Tsai.
• Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
• Medicine (Baltimore). 2022 Sep 9; 101 (36): e30493e30493.

RationalePlasma cell-rich acute rejection (PCAR), a subtype of T cell-mediated rejection, is a relatively rare type of acute allograft rejection, that is usually associated with a higher rate of graft failure. However, it is difficult to diagnose PCAR precisely.Patient ConcernsA 45-year-old woman who had received a kidney transplant presented with acute kidney injury and uremic symptoms approximately 1 year after transplantation.DiagnosisA renal biopsy was performed and pathological examination revealed marked inflammation with abundant plasma cells in areas within interstitial fibrosis and tubular atrophy. The patient was diagnosed with PCAR and chronic active T cell-mediated rejection (CA-TCMR) grade IA.InterventionsImmunosuppressants were administered as tacrolimus (2 mg twice daily), mycophenolate mofetil (250 mg twice daily), and prednisolone (15 mg/day) for suspected PCAR.OutcomesThe patients showed rapid deterioration in kidney function and reached impending graft failure.LessonsPCAR is often associated with poor graft outcome. The high variability in tacrolimus levels could contribute to poor patient outcomes, leaving aggressive immunosuppressive therapy as the remaining choice for PCAR treatment.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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