DS had three pregnancies with high complication rates, the first ending in miscarriage and the second complicated by preeclampsia. The third pregnancy was characterized by hypertension and proteinuria at 26 weeks, and gestational diabetes. She was induced for preeclampsia at 34 weeks and delivered by caesarean section. Post partum she became increasingly unwell and at six weeks

post partum was found to RAD001 be in acute renal failure with thrombotic microangiopathy (TMA). Renal biopsy confirmed vascular and glomerular changes typical of aHUS. She underwent plasma exchange that was unsuccessful and was commenced on haemodialysis. There was no recovery of renal function. There is no family history of kidney disease or aHUS. DS spent 5 years on dialysis before being listed for transplantation. Peritoneal dialysis had failed and she had significant vascular access problems with recurrent thromboses. She was counselled regarding the risk of recurrent aHUS and graft loss post transplant. DS proceeded to renal transplant (brain death donor[DBD]) on 26 November 2011. There was a 5 HLA mismatch; she was unsensitized with Luminex class I and II negative screens pretransplant. Both donor and recipient were CMV/EBV positive and she received standard induction

therapy with basiliximab and maintenance tacrolimus, mycophenolate mofetil and prednisone. The operation Adenosine was uncomplicated and implantation biopsy showed acute tubular necrosis DAPT (ATN) and mild arteriosclerosis. Early graft function was good

with a rapid fall in serum creatinine from 700 to 110 μmol/L (see Fig. 1). She developed urosepsis with Proteus mirablis and Klebsiella oxytoca bacteraemia on day 5 and was treated with intravenous antibiotics. On day 14 her serum creatinine rose to 173 μmol/L, with no evidence of TMA. Peripheral blood film showed no schistocytes or reticulocytosis, Hb was stable at 73 g/L, platelets 161 × 109, WCC 8.1 × 109/L with lymphopenia (0.54 × 109/L) but a normal neutrophil count (7.01 × 109/L); LDH was 154 U/L. She was treated with pulse methylprednisolone over the weekend prior to a biopsy. On day 16 a renal biopsy showed severe vascular rejection (v3), moderate micro vascular inflammation (g2, ptc2), acute tubular necrosis and moderate tubulointerstitial inflammation (i2, i2) (Fig. 2a). C4d was negative in peritubular capillaries and glomerular capillaries but appeared to stain arteriolar endothelium. She underwent plasma exchange and was commenced on thymoglobulin and IVIG. Tacrolimus was withheld for 5 days during thymoglobulin treatment. Prior to instigating thymoglobulin, tacrolimus levels had been therapeutic and ranged between 3.8 and 9.2 μg/L. Levels were unrecordable during the period it was withheld and remained therapeutic during the remainder of treatment.