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Kidney Week

Abstract: PO2223

Immunosuppression Cessation During Chemotherapy for Post-Transplant Lymphoproliferative Disorders in Kidney Transplant Recipients

Session Information

Category: Transplantation

  • 1902 Transplantation: Clinical

Authors

  • Atari, Mohammad, Tulane University School of Medicine, New Orleans, Louisiana, United States
  • Alper, Arnold B., Tulane University School of Medicine, New Orleans, Louisiana, United States
  • Giusti, Sixto G., Tulane University School of Medicine, New Orleans, Louisiana, United States
Introduction

Kidney transplant patients have a 20-fold higher risk to develop Post-Transplant Lymphoproliferative disorder (PTLD). PTLD requires reduction in immunosuppression (IS) medications to the lowest dose that prevents rejection. Here we report the safe withdrawal of IS in three kidney transplant recipients with PTLD receiving chemotherapy.

Case Description

Case 1: A 44-year-old male received a deceased donor renal transplant with alemtuzumab induction. He developed cellular rejection that was treated with steroids and thymoglobulin. He was maintained on cyclosporine, mycophenolate, and prednisone. Later on, he developed resistant EBV viremia and a retroperitoneal mass with diffuse lymphadenopathy. Biopsy revealed a high-grade, EBV-negative, monomorphic diffuse large B cell lymphoma (DLBL). IS medications were stopped except for low-dose prednisone. Creatinine remained stable post six cycles of chemotherapy, with complete response after three cycles.
Case 2: A 59-year-old male with a history of membranous nephropathy (MN) treated with rituximab. Received a living-related donor renal transplant (LRDRT), with alemtuzumab induction. MN recured three years after transplantation and was treated with modified Ponticelli protocol. He was maintained on cyclosporine and mycophenolate. Ten years post-transplant, he had a large mesenteric soft tissue mass with lymphadenopathy. Biopsy showed EBV-negative, monomorphic high-grade DLBL. IS medications were stopped. The patient received six cycles of chemotherapy and achieved a complete response. Creatinine remained at baseline.
Case 3: A 36-year-old male with a history of IgA nephropathy, received a LRDRT with alemtuzumab induction. He was maintained on tacrolimus and mycophenolate. Five months later, he was diagnosed with stage IIIB, EBV-positive, monomorphic DLBL via tonsillar mass biopsy. IS medications were stopped and he went into complete remission after eight cycles of chemotherapy. He was started on sirolimus monotherapy post-chemotherapy. Creatinine remained at baseline for five years.

Discussion

IS withdrawal seems to be a safe option during chemotherapy for PTLD. Chemotherapy causes prolonged immunosuppression or immune tolerance to the allograft. The safe cessation of IS while receiving chemotherapy for PTLD has been described, with reinstitution of low-dose IS post-remission.