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Abstract: PO2554

A Case of Antibody-Mediated Rejection (ABMR) After Withdrawal of Etanercept in a Renal Transplant Recipient

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Uy, Iris Jill Estrada, Johns Hopkins Medicine, Baltimore, Maryland, United States
  • Abuzeineh, Mohammad, Johns Hopkins Medicine, Baltimore, Maryland, United States
  • Alasfar, Sami, Johns Hopkins Medicine, Baltimore, Maryland, United States
  • Naqvi, Fizza F., Johns Hopkins Medicine, Baltimore, Maryland, United States
  • Trollinger, Brandon L., Johns Hopkins Medicine, Baltimore, Maryland, United States
Introduction

Etanercept is a tumor necrosis factor (TNF) receptor fusion protein that is used to manage several forms of inflammatory arthritis and psoriasis. Herein, we present a renal transplant recipient who was concomitantly treated with Etanercept for psoriasis and subsequently developed two episodes of ABMR after the drug’s withdrawal

Case Description

A 41-year-old man with history of psoriasis and end stage renal disease due to hypertensive nephrosclerosis and interstitial nephritis who underwent living related kidney transplant from his brother in December 2008. He was being treated for psoriasis with Etanercept which was withdrawn in September 2012. Subsequently he had rising serum creatinine (Cr) from baseline of 1.3 to 1.6 mg/dL and developed de-novo donor specific antibodies (DSA) to DR11 and DQ7 with positive cytotoxicity crossmatch. Renal allograft biopsy showed evidence of Banff 2A acute cellular rejection, ABMR, chronic glomerulonephritis and interstitial nephritis. He was treated with high dose steroids, 10 sessions of plasmapheresis with intravenous immunoglobulin (IVIG), and Rituximab. His Cr improved to 1.2 mg/dL but DSA remained positive. Later on he was restarted on Etanercept which was withdrawn again in March 2019. Accordingly, in September 2019, he developed acute kidney injury with Cr up to 1.7 from baseline of 1.3-1.5 mg/dL associated with nephrotic range proteinuria. He had a rise in DSA to DQ7, and developed new DSA to A2 and B60 with positive cytotoxicity crossmatch. Donor derived cell free DNA was elevated at 4.4%. Allograft biopsy showed glomerulitis, peritubular capillaritis with positive c4d, consistent with ABMR. He was treated with high dose steroids, 5 sessions of plasmapheresis with IVIG and Rituximab. Repeat DSA showed reduction in A2, but no change in DQ7. His serum Cr improved but his proteinuria remained at nephrotic range

Discussion

Despite the use of Etanercept in the treatment of graft versus host disease among transplant recipients, it hasn't been studied as a potential immunosuppressive drug. In our patient, Etanercept seemed to provide anti-rejection effect as shown by two episodes of ABMR with de-novo DSA after the drug's withdrawal. Close monitoring of renal function and DSA may be warranted once Etanercept or other TNF inhibitors are withdrawn in transplant recipients