Postpartum Triple Allograft Injury with Atypical Hemolytic Uremic Syndrome, Recurrent IgA Nephropathy, and Antibody-Mediated Rejection in a Kidney Retransplant Recipient: A Case Report

Abstract

Background: The concurrent presentation of chronic hypertension with superimposed preeclampsia, postpartum atypical hemolytic uremic syndrome (aHUS), recurrent IgA nephropathy (IgAN), and antibody-mediated rejection (ABMR) constitutes a life-threatening clinical emergency. To the best of our knowledge, the coexistence of all these complications has rarely been documented in the literature, representing an extremely rare clinical phenotype. Methods: This study presents a 33-year-old female who had undergone two prior living-donor kidney transplantations. She underwent emergency cesarean section at 32 weeks of gestation due to threatened uterine rupture superimposed with preeclampsia. Postoperatively, allograft function deteriorated rapidly. Renal allograft biopsy confirmed triple pathological lesions including recurrent IgAN, aHUS, and ABMR. Genetic testing detected no pathogenic mutations classically associated with aHUS. Results: The patient received targeted complement inhibition with eculizumab combined with intensified anti-rejection therapy and renal replacement therapy. Hemolysis-related parameters showed only transient improvement while the condition progressed continuously. The patient eventually died of multiple organ failure five months postpartum. Conclusions: This case highlights the need to differentiate multiple concurrent etiologies in second living-donor kidney transplant recipients with post-pregnancy renal decline. Thrombotic microangiopathy, recurrent primary renal disease, and allograft rejection should be suspected in postpartum patients with renal injury, thrombocytopenia, and anemia. Despite early biopsy and combination therapy, this severe complication constellation has a dismal prognosis and can cause fatal multiple organ failure, reflecting diagnostic challenges and therapeutic limitations in this rare presentation.