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Kidney Week

Abstract: PO2473

Acute Rejection and Graft Failure in a Kidney Transplant Recipient with Malignant Melanoma and Treated with Pembrolizumab: A Case Report

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Panthofer, Annalise Marie, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
  • Swanson, Kurtis J., University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
  • Mandelbrot, Didier A., University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
  • Garg, Neetika, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
Introduction

Malignancy treatment with immunotherapy in renal transplant recipients is complicated by a very high risk of rejection. Immunochemotherapy increases immune recognition and destruction of immune-evading cancer cells. This can lead to an overly robust immune response leading to allograft injury and failure. Here we present a case of graft failure due to rejection within a week of starting immunochemotherapy.

Case Description

73-year-old female with a history of end-stage renal disease attributed to hypertensive nephrosclerosis underwent live unrelated kidney donor transplant and presented 6 months post-transplant with a right foot lesion and was diagnosed with stage IIIC malignant melanoma. Her maintenance immunosuppression was decreased from tacrolimus/prednisone to prednisone monotherapy and the lesion was excised. 14 months later, disease surveillance via PET scan revealed metastatic disease. After carefully weighing the risks of mortality without treatment versus graft rejection, pembrolizumab, a programmed cell death one (PD-1) -inhibitor, was initiated. 5 days after administration of the first dose, the patient presented emergently with acute kidney injury with Cr of 4.3 mg/dL, increased from baseline Cr of 0.9-1.0 mg/dL. Ultrasound of her graft demonstrated significant edema and graft thrombosis. Allograft biopsy was consistent with 95% cortical necrosis with thrombotic microangiopathy and grade III acute cellular and antibody mediated rejection. Transplant nephrectomy was performed on day 7 and HD was re-initiated.

Discussion

Immune checkpoint inhibitors have been shown to be effective treatments for certain malignancies (melanoma, renal cell carcinoma namely); however, they can cause acute rejection and graft loss in transplant recipients. Though PD-1 inhibition has been a major scientific breakthrough in late-stage cancer treatment, its risks should be carefully considered in organ transplant recipients due to high risk of graft rejection. Prevention and management of rejection in a transplant recipient with an aggressive melanoma such as ours is not clear.