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Kidney Week

Abstract: PO2428

Chronic Graft vs. Host Disease in Pancreas After Kidney Transplant Recipient: An Unrecognized Entity

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Singh, Prince, Mayo Clinic Minnesota, Rochester, Minnesota, United States
  • Kukla, Aleksandra, Mayo Clinic Minnesota, Rochester, Minnesota, United States
Introduction

Graft-versus-host disease (GVHD), a common complication after allogenic bone marrow transplantation is rarely seen after solid organ transplants (SOT). Reports of acute GVHD (maculopapular rash, diarrhea and cholestatic liver disease) described after SOT invariably happened in the early post-transplant period (days to months). In contrast, reports of SOT recipients with clinical features more consistent with chronic GVHD (cGVHD) (resembling autoimmune disease with chronic inflammation/fibrosis) are lacking. We present a case of cGVHD in pancreas after kidney transplant (PAK) recipient diagnosed at 42 months post transplant.

Case Description

A 43 year old man received a HLA 5/6 mismatch, CMV mismatch (donor positive, recipient negative) deceased donor pancreas transplant two years after receiving a HLA 5/6 mismatch living unrelated kidney transplant. Anti-thymocyte globulin induction was given along with a maintenance immunosuppression - tacrolimus, mycophenolate mofetil and prednisone.

Post-transplant course was complicated by multiple opportunistic infections (Figure 1) leading to immunosuppression reduction. At 42 months post transplant, he developed dry eyes, arthralgia, anorexia, elevated alkaline phosphatase, dyspnea on exertion, lichen simplex chronicus dermatitis, and severe pancytopenia. GVHD was suspected which lead to peripheral blood chimerism testing revealing 90% pancreas donor-derived DNA in CD3-positive fraction of T cells. Patient passed away.

Discussion

The infections may have represented the immune dysfunction associated with cGVHD. De-escalation of immunosuppression could have led to an unopposed activation of donor cytotoxic T-lymphocytes resulting in worsening GVHD. Donor-derived T lymphocytes received during pancreas transplant may have targeted the bone marrow, causing severe pancytopenia,hence compounding the dysregulated immune state.
Transplant professionals should be aware of the possibility of the rare but challenging diagnosis of cGVHD in PAK recipients and hence identify it appropriately.