SUCCESSFUL RENAL TRANSPLANTATION IN A PATIENT WITH ATYPICAL HAEMOLYTIC-URAEMIC SYNDROME FOLLOWING ALLOGENEIC HAEMATOPOIETIC STEM CELL TRANSPLANT
SOPHIE O’BRIEN1, KRISTEEN BARKER2
1Western Health, Australia, 2Alfred Health, Australia
Background: Thrombotic microangiopathy (TMA) leading to renal failure after allogeneic hematopoietic stem cell transplant (HSCT) presents a complex and challenging clinical picture. Establishing the aetiology of TMA in these patients is difficult, and treatment with eculizumab represents a significant healthcare cost. In this setting, clinicians might be reluctant to proceed with renal transplantation because of concern around precipitating TMA, particularly where access to eculizumab is limited.
Case report: We describe the case of a 30-year-old female with B-cell acute lymphoblastic leukaemia who received an allogeneic HSCT in 2014. Post-transplant immunosuppression included cyclosporin followed by sirolimus. Subsequently, she had a series of infective complications, and developed renal failure after 10 months. She was diagnosed with atypical haemolytic-uraemic syndrome (aHUS) and received eculizumab therapy for 30 months. Renal transplant from a deceased donor was performed in 2018, utilising a post-transplant immunosuppression regimen featuring basiliximab and methylprednisolone at induction, mycophenolate, prednisolone and reduced intensity calcineurin inhibitor (CNI) exposure with tacrolimus (target trough levels 4-5ng/mL month one, 5-7ng/mL thereafter). The graft is functioning well after more than five years, with no rejection episodes or recurrence of aHUS.
Conclusions: Renal transplantation without eculizumab is a viable option in patients with TMA after HSCT. Strategies employed in this case to reduce risk of TMA recurrence included minimising transplant organ ischaemia, and reduced intensity CNI in the early post-transplant period. Renal transplantation following HSCT-associated TMA may be seen more often in future by transplant physicians, and further research is required into its management.