Abstract: FR-PO672
Renal Microangiopathy and Tubulitis Following Haploidentical Stem Cell Transplant with α/β T Cell and CD19 B Cell Depletion
Session Information
- Electrolytes and Cancer Trainee Case Reports
November 08, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 1500 Onco-Nephrology
Authors
- Hertz-Tang, Amber, University of Wisconsin Madison, Madison, Wisconsin, United States
- Kenkre, Vaishalee P., University of Wisconsin Madison, Madison, Wisconsin, United States
- Zhong, Weixiong, University of Wisconsin Madison, Madison, Wisconsin, United States
- Yang, David, University of Wisconsin Madison, Madison, Wisconsin, United States
- Djamali, Arjang, University of Wisconsin Madison, Madison, Wisconsin, United States
- Bhutani, Gauri, University of Wisconsin Madison, Madison, Wisconsin, United States
Introduction
Selective depletion of α/β T-cells and CD19 B-cells in haploidentical (haplo) hematopoietic stem cell transplantation (HSCT) is being investigated as a strategy to avoid graft versus host disease (GVHD) while preserving immune reconstitution. We describe 4 cases of renal dysfunction following haplo-HSCT.
Case Description
All cases were Caucasian males who underwent non-myeloablative peripheral blood haplo-HSCT using fludarabine, cyclophosphamide and total nodal irradiation (7Gy). All reached engraftment and received mycophenolate (MMF) for GVHD prophylaxis (30 days). All are living at last follow up. The table summarizes their presentations.
Discussion
All patients had endothelial injury and most (3/4) had inflammatory tubular pathology. Given the setting of haplo-HSCT with selective T-cell depletion, timeline and degree of renal insult, as well as response to IS, renal complications were most concerning for alloimmune response (GVHD). Chemotherapy and pre-IS infections may also have contributed to endothelial/tubular injury in early post-HSCT period. Our series highlights (1) GVHD is likely an important factor in post haplo-HSCT endothelial injury and direct/indirect tubular injury; (2) This condition is difficult to treat due to high risk of infections post-HSCT. Renal risks in haplo-HSCT need further investigation.
| Case 1 | Case 2 | Case 3 | Case 4 | |
| Diagnosis | Chronic Lymphocytic Leukemia | Marginal Zone Lymphoma | Peripheral T-Cell Lymphoma | Mantle Cell Lymphoma |
| Age at HSCT | 52 | 57 | 55 | 65 |
| Baseline serum creatinine (mg/dl) (eGFR mL/min/1.73sqm) pre-HSCT | 1.06 (85) | 1.63 (46) | 0.89 (93) | 1.03 (72) |
| Total follow up post-HSCT (days) | 1021 | 491 | 315 | 301 |
| Time to 50% GFR loss (days) | 127 | 199 | 277 | 155 |
| Renal pathology | Thrombotic microangiopathy (TMA) and active tubulointerstitial nephritis (TIN) | Severe chronic active TIN and TMA | Mild chronic and active TMA and acute tubular necrosis (ATN) | ATN, TIN, TIN and chronic active TMA |
| Infections [pre-immuno-suppression (IS)] | CMV | None | ●CMV ●C.diff | C.diff |
| Other organ dysfunction (days post-HSCT) | Skin-GVHD confirmed (29) | None | ●Skin-GVHD presumed (33) ●Gut-GVHD confirmed (176) ●Pulmonary hypertension (308) | ●Skin-GVHD confirmed (45) ●Lung-GVHD presumed (129) ●Pulmonary hypertension (82) |
| GVHD treatment | ●Prednisone ●MMF ●Rituximab ●Eculizumab -Renal indication | ●Prednisone ●MMF ●Etanercept -Renal indication | Prednisone -GI indication | ●Prednisone ●Sirolimus -Pulmonary indication |
| Infections (post-IS) | ●Aspergillus ●Pseudomonas ●Influenza A | ●Strep pneumo ●C.diff ●Parapertusis ●Adenovirus | ●H.influenza ●RSV | ●MSSA ●Pseudomonas ●E.coli sepsis |
| Renal response | Partial response (PR) to IS. Progressed to ESRD with infections. | PR to IS. Progressed to ESRD with infections. | PR to IS. Last known serum creatinine:2.36 eGFR:29 | No IS given for renal disease. Progressed to ESRD in setting of infections and cardiac disease |