Abstract: TH-PO1047
Walking a Tightrope of Immunosuppression: Treating High-Risk Smoldering Multiple Myeloma in a Kidney Transplant Recipient with BK Virus and Cytomegalovirus (CMV) Coinfection
Session Information
- Transplantation: Clinical - Outcomes, Malignancy, and Pathology
October 22, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Khan, Saila Azam, New York University Grossman School of Medicine, New York, New York, United States
- Bailey, Ronelle, New York University Grossman School of Medicine, New York, New York, United States
- Drakakis, James, New York University Grossman School of Medicine, New York, New York, United States
Introduction
The development of novel agents to treat multiple myeloma (MM) has improved outcomes dramatically. However, it has also led to an increasing incidence of post transplant cytomegalovirus (CMV) reactivation. This has been studied in the realm of stem cell transplantation. Also, recognized, are chimeric antigen receptor (CAR) T cells which have expanded the therapeitic landscape in MM (and also lymphomas), but have also led to significantly more viral infections, including BK. Our case appears to be the first to describe a kidney transplant patient with high risk smoldering MM, treated with D-CyBorD, who developed worsening CMV & BK co-infections. The management strategy involved a very delicate balance of immunosupression with close multi-disciplinary involvement and laboratory surveillance.
Case Description
73 year old male with past history of ESRD due to FSGS, having undergone a living related kidney transplant in 2018. Serum creatinine mostly 1.0 mg/dL. About 7 years post transplant, proteinuria worsened to 1.0 - 1.5 g/g and workup revealed an IgG kappa monoclonal protein on serum immunofixation. Serum immunoglobulin G 6633 with reciprocal lowering of immunoglobulins A and M. Serum free kappa light chain 885 mg/L, serum free lambda light chain 20.8 mg/L and kappa/lambda ratio 42.56. Bone marrow biopsy revealed 40% plasma cells. Taken together, this constellation felt to be consistent with high risk smoldering MM. At the time of diagnosis, CMV PCR 106 IU/mL and BK virus <21.5 IU/mL. D-CyBorD initiated and by 2 months later CMV rose to 56,000 IU/mL and BK to 72,000 IU/mL. As complete remission ultimately achieved, the regimen was adjusted to D-RVd,with a subsequent stepwise holding of agents to successfully ameliorate viremias.
Discussion
In kidney transplant reciepents, established risk factors for viremias include lymphopenia, prolonged corticosteroid exposure, and intensive immunosuppression. In our case, the start of D-CyBorD for high risk smoldering MM, contributed to the development of both BK and CMV infections with a large increase in viral load compared to pre-therapy values. There are currently no well established evidence based treatment guidlines for managing these viruses in such a setting. Our case illustrates one particular approach in kidney transplant to navigating MM therapy, in lieu of dual BK and CMV infections.