J Korean Soc Transplant.  2016 Mar;30(1):38-43. 10.4285/jkstn.2016.30.1.38.

Overcome of Drug Induced Thrombotic Microangiopathy after Kidney Transplantation by Using Belatacept for Maintenance Immunosuppression

• Yun SH
• Lee JH
• Oh JS
• Kim SM
• Sin YH
• Kim YJ
• Kim JK

• KMID: 2202627
• DOI: http://doi.org/10.4285/jkstn.2016.30.1.38

Abstract

Thrombotic microangiopathy (TMA) is a serious complication of solid organ transplantation. Drug-induced TMA is typically caused by immunosuppressants, particularly calcineurin inhibitors. Withdrawing the causative drug can be one of the treatments for TMA. However, the more immunosuppressants are reduced, the more risk of rejection increases. Even if TMA is successfully resolved, the outcomes of patient and graft survival would be worse than expected. Therefore, it is necessary to maintain efficient and safe immunosuppression therapy. We report on a case of de novo TMA after kidney transplantation triggered by tacrolimus and reactivated by sirolimus. Belatacept, a novel CTLA4 Ig fusion protein, was administered for maintenance immunosuppressant with mycophenolate mofetil and prednisolon. The patient had excellent early graft outcome, and there have been no adverse events so far.

Keyword

Belatacept; Kidney transplantation; Thrombotic microangiopathies

MeSH Terms

Abatacept
Calcineurin
Graft Survival
Humans
Immunosuppression*
Immunosuppressive Agents
Kidney Transplantation*
Kidney*
Organ Transplantation
Sirolimus
Tacrolimus
Thrombotic Microangiopathies*
Transplants
Calcineurin
Immunosuppressive Agents
Sirolimus
Tacrolimus

Figure

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  Fig. 1. Changes in treatment progresses. (A) Platelet count and lactate dehydrogenase (LDH). (B) Creatinine and hemoglobin. (A, B) Period with the treatment: tacrolimus (1st), postoperative day (POD) 1∼2; thymoglobulin (1st), POD 3∼7; tacrolimus (2nd), POD 7∼9; sirolimus, POD 9∼ 10; thymoglobulin (2nd), POD 10∼ 17; cyclophosphamide, POD 19∼47; belatacept, POD 60≥; mycophenolate mofetil, POD 1∼; prednisolon, POD 1∼; plasmapheresis, POD 13; ureterocystostomy, POD 14; biopsy (1st), POD 26; biopsy (2nd), POD 111.

• 

  Fig. 2. The first biopsy revealed microthrombi (arrows) in glomerular capillary lumina (trichrome stain, ×400).

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  Fig. 3. The third biopsy showed no inflammatory cell infiltration both in glomeruli and interstitium. Focal mesangial cell proliferation (arrow) was noted as the sequel of thrombotic microangiopathy (PAS stain, ×200).

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