Abstract: SA-PO1145
Angiotensin II Type 1 Receptor Antibody (AT1-R Ab) Mediated Rejection in HLA-Incompatible Kidney Transplant Recipient
Session Information
- Transplant Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 1902 Transplantation: Clinical
Authors
- Kyeso, Yousuf, Johns Hopkins Hopsital, Baltimore, Maryland, United States
- Alasfar, Sami, Johns Hopkins Hopsital, Baltimore, Maryland, United States
- Alachkar, Nada, Johns Hopkins Hospital, Baltimore, Maryland, United States
Introduction
Donor-specific antibodies (DSAs) create an immunologic barrier to transplantation. The IgG degrading enzyme derived from Streptococcus pyogenes (IdeS), an endopeptidase, cleaves human IgG into F(ab′)2 and Fc fragments inhibiting complement-dependent cytotoxicity and antibody-dependent cellular cytotoxicity. We report unique case of non-HLA antibody mediated rejection in IdeS recipient
Case Description
A 40 years old male with history of ESRD due to IgA nephropathy who received IdeS as part of a phase 2 IRB approved trial in preparation for positive flow crossmatch deceased donor kidney transplant. Immediately post IdeS his crossmatch became negative. Patient also received IV alemtuzumab and rituximab for induction as part of the study protocol. One-week post-transplant, HLA-DSA rose to the cytotoxicity positive level and he was empirically treated for antibody mediated rejection with 11 sessions of plasmapheresis and intravenous immunoglobulin (IVIg). His HLA-DSA became flow negative. Maintenance immunosuppression included prednisone 5 mg daily, tacrolimus, and mycophenolate mofetil 1-gram BID.
Six months later, laboratory data revealed an increase in serum Cr from 1.0 to 1.4 mg/dL and HLA-DSA remained flow negative. Further histocompatibility testing showed increase in pre-transplant level of AT1-R Ab from 14 units/ml to > 40 units/ml (positive:>17 units/ml). Kidney pathology detected chronic active antibody mediated rejection. Patient was immediately started on IV solumedrol and losartan 50 mg daily, he also finished 5 sessions of plasmapheresis and IVIg. One week later, serum Cr trended down to 1.0 mg/dL and AT1-R Ab level dramatically improved to 10 units/ml.
Discussion
Although reduction of HLA-DSA with therapies such IdeS has allowed successful transplantation in highly sensitized patients, screening and surveillance for non-HLA antibodies such as AT1-R antibodies may be required in this high-risk population to prevent antibody mediated rejection