Kidney Week

Abstract: TH-PO831

Tocilizumab in the Treatment of Allograft Rejection in an HIV-Positive Kidney Transplant Recipient

Session Information

• Transplantation: Clinical - 2
  October 24, 2024 | Location: Exhibit Hall, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Transplantation

• 2102 Transplantation: Clinical

Authors

• Wickramasinghe, Kavindya, University of Virginia School of Medicine, Charlottesville, Virginia, United States

Kavindya Wickramasinghe

• Nguyen, Joseph D., University of Virginia School of Medicine, Charlottesville, Virginia, United States

Joseph D. Nguyen

• Murphy, Joel D., Arkana Laboratories, Little Rock, Arkansas, United States

Joel D. Murphy, MD

• Glass, William F., University of Virginia Department of Pathology, Charlottesville, Virginia, United States

William F. Glass, MD, PhD

• Rao, Swati, University of Virginia, Charlottesville, Virginia, United States

Swati Rao, MBBS

Introduction

Chronic active antibody-mediated rejection (CAAbMR) in kidney transplant recipients (KTRs) is a major cause of late graft loss and responds poorly to standard-of-care (SOC) immunosuppression (steroids, IVIG, plasmapheresis). Recently, tocilizumab (TCZ), an IL-6 receptor antagonist affecting multiple pathways involved in B-, T-, and plasma cell activity, has been utilized in the treatment of CAAbMR. However, escalating immunosuppression in patients with chronic infections, such as HIV and HBV, can increase the risk of viral reactivation. We report a successful case of TCZ used to treat refractory allograft rejection in a KTR with chronic HIV and HBV.

Case Description

A 56-year-old male with well-controlled HIV and HBV, with ESKD from HIV nephropathy, received a deceased donor kidney transplant in 2016. After enjoying good allograft function for 5 years, he developed proteinuria (1 g/d) with low-level donor specific antibodies. Kidney biopsy demonstrated CAAbMR (fig. 1a/b). As the patient demonstrated no response to SOC treatment (fig. 1c/d), he was started on TCZ. During the 1-year treatment course, serial monitoring of HIV and HBV was conducted. He did not develop viremia and CD4 count remained over 200 cells/mm³. One episode of cellulitis was treated with IV antibiotics. The Cr remains 1 mg/dl, proteinuria has improved (0.3 g/d), and the allograft biopsy shows improvement in CAAbMR (fig. 1e/f).

Discussion

As with all immunosuppressive medications, TCZ use in KTRs has been associated with infections. Extrapolating from the safety of short-term TCZ in HIV patients during the COVID-19 pandemic, we opted for long-term TCZ for treatment of refractory CAAbMR in our patient, with serial viral load monitoring. To the authors’ knowledge, this is the first case report demonstrating the successful use of TCZ in a KTR with HIV and HBV.

Figure 1. Biopsy after SOC therapy for CAAbMR showing lack of efficacy (g3,ptc3,cg1). Biopsy after 6 months (c/d) and 12 months (e/f) of TCZ showing improvement (g2,ptc2,cg1b) and minimal IFTA.