Recalcitrant Vascular Rejection
Recalcitrant Vascular Rejection
How would you treat a C4d-negative, donor-specific antibody-negative, "recalcitrant" vascular rejection in a 34-year-old white male? He is 4 weeks status post living-donor kidney transplantation; he received daclizumab induction therapy and is on tacrolimus and mycophenolate mofetil maintenance immunosuppression. Two weeks ago, he received a 5-day course of OKT3 (for 5 days) and was doing well until he came back again with rejection (biopsy shows more infiltrates and vasculitis).
This appears to be a very aggressive cellular rejection that was not adequately treated with OKT3. Short courses of low-dose OKT3 have been shown to be suboptimal therapy. Since there is no evidence of humoral rejection (although it would be important to find out if the patient has de novo non-donor-specific antibodies), the patient should be treated with a 10-day course of rATG and at a dosage that maintains the CD3-positive cell count below 100 (preferably below 50). In addition, since the patient will be at higher risk for cytomegalovirus (CMV) infection and posttransplant lymphoproliferative disease, prolonged effective therapy for CMV should be used (possibly for 6 months) and Epstein-Barr viral loads should be monitored.
How would you treat a C4d-negative, donor-specific antibody-negative, "recalcitrant" vascular rejection in a 34-year-old white male? He is 4 weeks status post living-donor kidney transplantation; he received daclizumab induction therapy and is on tacrolimus and mycophenolate mofetil maintenance immunosuppression. Two weeks ago, he received a 5-day course of OKT3 (for 5 days) and was doing well until he came back again with rejection (biopsy shows more infiltrates and vasculitis).
This appears to be a very aggressive cellular rejection that was not adequately treated with OKT3. Short courses of low-dose OKT3 have been shown to be suboptimal therapy. Since there is no evidence of humoral rejection (although it would be important to find out if the patient has de novo non-donor-specific antibodies), the patient should be treated with a 10-day course of rATG and at a dosage that maintains the CD3-positive cell count below 100 (preferably below 50). In addition, since the patient will be at higher risk for cytomegalovirus (CMV) infection and posttransplant lymphoproliferative disease, prolonged effective therapy for CMV should be used (possibly for 6 months) and Epstein-Barr viral loads should be monitored.
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