Abstract: TH-PO591
Clinical Tolerance - A Rare but Highly Deserved State of the Post-Transplant Patient
Session Information
- Trainee Case Reports - II
October 25, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1802 Transplantation: Clinical
Authors
- Chowdhury, Monzurul, UMASS Memorial, Worcester, Massachusetts, United States
- Bodziak, Kenneth A., UMass Memorial Medical Center, Worcester, Massachusetts, United States
Introduction
Graft tolerance is a clinical situation defined as stable graft function without clinical features of chronic rejection, and in the absence of any immunosuppressive drugs, usually for longer than 1 year’s duration. This is observed more frequently in liver transplant patients but spontaneous graft tolerance has also been rarely reported in kidney allograft recipients. Many of these patients with presumed tolerance, in fact, are detected when they report to the treating physician with near normal graft function, but in the absence of immunosuppression. We present a case of immune tolerance following kidney transplant in an individual with normal graft function who had gone 10+ years without any immunosuppression.
Case Description
62-year-old male with the history of DM II, hypertension, renal stone, past deceased donor kidney transplant (2002) presented with chief complaint of abdominal pain, fever, and diarrhea for one week. His CT of the abdomen and pelvis showed a perforated appendix and was treated with antibiotics and the abscess was drained. He recovered from his current illness and his discharge creatinine was 1.07 mg/dL with eGFR 75 ml/min.
He received an HLA-matched deceased donor kidney transplant on 2002. His postoperative course was uncomplicated and creatinine improved from 5 mg/dL to 2 mg/dL at discharge. He was discharged on tacrolimus, mycophenolate, and prednisone. He gradually lost follow-up and stopped taking all of his medications, including his immunosuppressants, for more than 10 years on his own accord.
He preserved his renal function for all these years without any immunosuppressive medications. His chimerism study from buccal mucosal cells was negative but could not exclude microchimerism. He was subsequently discharged and maintained off immunosuppressive medications.
Discussion
The evolution of tolerance to donor alloantigen in vivo is a dynamic process involving many mechanisms that contribute at different stages. The clinical characteristics of tolerance patients are limited due to its rare occurrence. Our patient gradually discontinued his immunosuppressive over the course of months by himself. The possible mechanisms for his immune tolerance could be central (intrathymic) deletion, peripheral deletion, anergy, ignorance and/or microchimerism, either alone or in combinations. He still maintains a good graft function without any immunosuppressant.