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Kidney Week

Abstract: PO2475

Local Renal Graft Irradiation as Salvage Treatment for Rejection Secondary to Checkpoint Inhibitor: A Case Report

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical


  • Acuna-Morin, Edgar Eugenio, University of Miami, Miami, Florida, United States
  • Garcia Valencia, Oscar Alejandro, University of Miami, Miami, Florida, United States
  • Pagan, Javier, University of Miami, Miami, Florida, United States

Graft rejection after treatment for malignancies with checkpoint inhibitors targeting the CTLA-4 and the PD-L1 pathways has been a growing interest in recent years since the rates of graft rejection are high as 33.3% with a median time to rejection of 8 days. To the best of our knowledge, there are no prior case reports of a renal transplant patient with stage IV gastric adenocarcinoma treated with pembrolizumab (a PD-1 inhibitor) who developed graft rejection and required local irradiation.

Case Description

This is a 65-year-old male with history of ESRD secondary to IgA nephropathy, chronic Hepatitis B and related donor kidney transplant who was diagnosed with gastric malignancy with peritoneal carcinomatosis and outlet obstructionafter 12 years of transplantation. Gastric adenocarcinoma was HER2 equivocal, FISH negative, MMR deficient, PDL1 positive. Initial therapy includede discontinuation of Tacrolimus, steroid monotherapy. Initial chemotherapy included 2 cycles of FLOT followed by ramucirumab. After finding disease progression at 6 months, he received a salvage chemotherapy with pembrolizumab. Two weeks after, presented to the ED with anuric AKI. A Mag-3 scan demonstrated good perfusion and a kidney biopsy showed cortex coagulative necrosis. High dose steroids and sirolimus were given with no response and required initiation of hemodialysis. In the following weeks, presented to the ED complaining of gross hematuria and clots. Cystoscopy with bladder biopsy was performed and showed no bladder origin and normal mucosa. The hematuria was found to be secondary to kidney graft rejection and he was started on high dose of steroids with mild improvement. Nephrectomy was not an option due to poor nutritional status and overall health condition. Palliative radiation therapy to the kidney was the only option for immunosuppression. He received local graft irradiation of 7.5 Gy in 5 fractions with resolution of hematuria.


The case illustrates first, that the use of checkpoint inhibitors in patients with kidney transplant conveys a high risk of severe irreversible allograft rejection and can occur after only one dose. Second, the viability of palliative radiation as a non-surgical option for acute kidney graft rejection causing symptomatic hematuria resistant to conventional immunosuppressant therapy.