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Abstract: PO0767

Late Rejection of Failed Renal Allograft Precipitated by COVID-19 in a Hemodialysis Patient (HD)

Session Information

Category: Trainee Case Report

  • 000 Coronavirus (COVID-19)

Authors

  • Arif, Ali, Temple University, Philadelphia, Pennsylvania, United States
  • Lee, Iris J., Temple University, Philadelphia, Pennsylvania, United States
  • Abdelwahab, Dina, Temple University, Philadelphia, Pennsylvania, United States
Introduction

We present a case report of an HD patient with a failed allograft that had been stable off immunosuppression who presented with acute allograft rejection in the setting of COVID-19 infection.

Case Description

50 y/o male with a history of hypertension, living-related kidney transplant in 2005 E.S.R.D after his allograft failed in 2018. The patient’s allograft remained stable off immunosuppression on HD until 3/2020, when the patient presented with severe allograft tenderness with no fever or evidence of urinary tract infection. An abdominal CT was consistent with allograft rejection. Abdominal pain resolved after IV steroids and initiation of low dose tacrolimus. He was discharged but returned 4 days later, with recurrent abdominal pain, fever and shortness of breath. CT chest was consistent with COVID19 pneumonia with a positive swab. His condition was complicated by acute respiratory failure and cytokine storm. Despite receiving Ankinra for COVID-19, our patient died.

Discussion

Failed allograft rejection for patients who initiate HD usually occurs within the first 6-12 months. Unless allograft failure occurs within a year of transplantation, many nephrologists complete withdrawal of immunosuppression in failed grafts after 4 months to decrease the risk of infections. In our case, the development of allograft rejection after stable long-term HD, is very unusual. We propose that the cytokine storm from COVID-19 in our patient provided the appropriate "danger signals" that triggered innate inflammation and augmented effector responses against the allograft. COVID-19 infection triggers a pro-inflammatory immune response,with IL-6 being a key cytokine that potentially drives T-cell effector responses and inhibits T-regulatory responses to donor allograft.