Early post-transplant recurrence of ANCA vasculitis while on belatacept maintenance immunosuppression

Post-transplant recurrence of ANCA-associated vasculitis (AAV) is infrequent, with recurrence within weeks of transplantation being even rarer. We describe an unusual case of AAV recurrence within 2 weeks post-transplant. Our patient received a deceased donor kidney transplant (KDPI 60%) after 6 yea...

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Bibliographic Details
Published in:Journal of nephrology 2023-05, Vol.36 (4), p.1169-1174
Main Authors: Agrawal, Amogh, Chong, Grace Yun, Fidler, Mary Elizabeth, Cramer II, Carl Henry, Amer, Hatem, Bentall, Andrew John
Format: Article
Language:English
Subjects:
Abatacept - adverse effects
Abatacept - therapeutic use
Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis - drug therapy
Case Report
Delayed Graft Function
Female
Humans
Immunosuppression Therapy
Kidney Failure, Chronic - therapy
Kidney Transplantation - adverse effects
Medicine
Medicine & Public Health
Middle Aged
Nephrology
Recurrence
Urology
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Summary:Post-transplant recurrence of ANCA-associated vasculitis (AAV) is infrequent, with recurrence within weeks of transplantation being even rarer. We describe an unusual case of AAV recurrence within 2 weeks post-transplant. Our patient received a deceased donor kidney transplant (KDPI 60%) after 6 years on hemodialysis for end-stage renal disease from AAV. She was induced with thymoglobulin and steroids, and maintained on belatacept, mycophenolate and prednisone. Time-zero biopsy showed acute tubular injury. Due to persistent delayed graft function by post-operative day 14, she underwent repeat biopsy, which showed focal segmental necrotizing and crescentic glomerulonephritis, with positive MPO, PR3 and negative anti-glomerular basement membrane antibodies. As her findings were in keeping with recurrent AAV, she underwent induction with rituximab, prednisone and intravenous immunoglobulin, with repeat rituximab 14 days later because of increasing B-lymphocyte counts. Belatacept was replaced with tacrolimus due to concerns with autoimmunity. Fortunately, renal function began to recover 4 days after treatment. In addition to highlighting potential immunologic mechanisms in AAV and the use of rituximab in post-transplant recurrence, our case suggests that for systemic autoimmune disease, patients maintained on belatacept must be monitored closely for recurrence, particularly in the setting of delayed graft function. Graphical Abstract
ISSN:1724-6059
1121-8428
1724-6059
DOI:10.1007/s40620-022-01556-x