Acute Allograft Rejection in Kidney Transplant Recipients Treated With Immune Checkpoint Inhibitors: An Educational Case Report.

IF 1.6 Q3 UROLOGY & NEPHROLOGY
Canadian Journal of Kidney Health and Disease Pub Date : 2024-10-21 eCollection Date: 2024-01-01 DOI:10.1177/20543581241289191
Steven A Morrison, Amanda J Vinson
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引用次数: 0

Abstract

Rationale: Kidney transplant (KT) recipients have an increased risk of malignancy due to chronic immunosuppression. The emerging use of immune checkpoint inhibitors (ICIs) has been a promising development for the treatment of malignancy, but their use adds to the complexity of immunosuppression management for KT recipients. This case report describes 2 cases of acute rejection in KT recipients following ICI initiation and discusses the balance of malignancy treatment with adequate immunosuppression.

Presenting concerns of patients: The first patient is a 44-year-old male KT recipient with a diagnosis of metastatic renal cell carcinoma presenting with acute kidney injury 6 days following initiation of an ICI. The second patient is a 73-year-old male KT recipient with a diagnosis of squamous cell carcinoma presenting with acute kidney injury 2 weeks following initiation of an ICI.

Diagnoses: Both patients were diagnosed with acute rejection in the setting of reduced immunosuppression and initiation of an ICI.

Interventions: Both cases received an increased dose of steroid without improvement of graft function. The first patient subsequently underwent a delayed graft nephrectomy due to complications of acute rejection, whereas the second patient did not undergo nephrectomy.

Outcomes: The first patient experienced complications including perioperative bleeding requiring multiple operations, but ultimately stabilized on hemodialysis and showed a durable response to ICI. The second patient remained dialysis-dependent post-ICI treatment and was readmitted with allograft complications leading to his eventual death.

Teaching points: This study underscores the complexity of managing KT recipients diagnosed with malignancy and receiving ICIs. The balance between immunosuppression reduction to treat malignancy and preventing allograft rejection presents a significant challenge. Key considerations include the risk of acute allograft rejection and patient-centered decision-making. These cases highlight the need for further research to develop evidence-based guidelines for managing this patient population. In addition, the patient perspective in this study highlights the importance of careful risk-benefit analysis and the impact of treatment decisions on patient-focused outcomes.

接受免疫检查点抑制剂治疗的肾移植受者出现急性移植物排斥反应:教育性病例报告。
理由:肾移植(KT)受者因长期免疫抑制而增加了罹患恶性肿瘤的风险。新出现的免疫检查点抑制剂(ICIs)在治疗恶性肿瘤方面前景广阔,但其使用增加了肾移植受者免疫抑制管理的复杂性。本病例报告描述了两例 KT 受者在使用 ICI 后出现急性排斥反应的病例,并讨论了恶性肿瘤治疗与适当免疫抑制之间的平衡问题:第一例患者是一名 44 岁的男性 KT 受体,诊断为转移性肾细胞癌,在使用 ICI 6 天后出现急性肾损伤。第二名患者是一名 73 岁的男性 KT 受体,诊断为鳞状细胞癌,在开始 ICI 2 周后出现急性肾损伤:两名患者均被诊断为在免疫抑制减少和开始使用 ICI 的情况下出现急性排斥反应:干预措施: 两例患者均接受了加大剂量的类固醇治疗,但移植功能均未得到改善。第一例患者随后因急性排斥反应并发症接受了延迟移植肾切除术,而第二例患者没有接受肾切除术:第一例患者出现了包括围手术期出血在内的并发症,需要进行多次手术,但最终通过血液透析稳定了病情,并对 ICI 表现出了持久的反应。第二名患者在接受 ICI 治疗后仍需依赖透析,并因异体移植并发症再次入院,最终导致死亡:本研究强调了管理确诊为恶性肿瘤并接受 ICI 的 KT 受体的复杂性。如何在减少免疫抑制以治疗恶性肿瘤和防止异体移植排斥反应之间取得平衡是一项重大挑战。主要考虑因素包括急性异体移植排斥反应的风险和以患者为中心的决策。这些病例凸显了进一步研究的必要性,以便为管理这一患者群体制定循证指南。此外,本研究从患者的角度强调了谨慎进行风险效益分析的重要性,以及治疗决策对以患者为中心的治疗效果的影响。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
3.00
自引率
5.90%
发文量
84
审稿时长
12 weeks
期刊介绍: Canadian Journal of Kidney Health and Disease, the official journal of the Canadian Society of Nephrology, is an open access, peer-reviewed online journal that encourages high quality submissions focused on clinical, translational and health services delivery research in the field of chronic kidney disease, dialysis, kidney transplantation and organ donation. Our mandate is to promote and advocate for kidney health as it impacts national and international communities. Basic science, translational studies and clinical studies will be peer reviewed and processed by an Editorial Board comprised of geographically diverse Canadian and international nephrologists, internists and allied health professionals; this Editorial Board is mandated to ensure highest quality publications.
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