U C 06- 467

1. UC06-467 F, 17 y.o., Montreal Children’s Hospital • Deceased donor allograft since 10 months • Developed an acute severe cellular rejection 8 months after transplantation which we are unable to control • Since her last biopsy, her serum creatinine continues to creep up, now 160 umol/l. Any comments, also in view of eventual retransplantation,will be appreciated.

2. Clinical history Montreal Children’s Hospital • Presented with end-stage renal disease in September 2004 • Bx: End-stage renal disease with : • Diffuse glomerulosclerosis with numerous hyalinosis lesions (>80% of sampled glomeruli ; FSGS?) • Partila collapse (ischemic?) of rare non-sclerosed glomeruli • Arterial/arteriolar changes consistent with severe hypertension • Advanced chronic tubulo-interstitial damage • No prior symptoms of nephrotic syndrome and no NPHS2 open reading frame mutation.

3. Underwent hemodialysis until receiving a deceased donor kidney on October 26, 2005 • young donor (23 kg) • one-antigen (DR) match • CMV and EBV -. • Patient was CMV + and EBV -. • Cold ischemia time: 7 ½ hours. • Warm ischemia time: 30 minutes. • No intra-operative complications • Urine output was immediate. • Developed a large pelvic hematoma requiring blood transfusions on the sixth post-operative day.

4. Patient’s mother fought hard for a steroid-free regimen. • We agreed to emulate the steroid-free arm of the SNS01 (Sarwal) study: • induction with extended Daclizumab infusions and immediate treatment with tacrolimus and MMF without any steroids except for rejection.

5. Had ATN in the immediate post-transplant period • Became anuric on post transplant day 3 (Oct 29th). • There was concern about the possibility of humoral rejection. SNS01 protocol was abandoned and IVIG and Thymoglobulin were instituted. • Urgent post-transplant biopsy on October 29, 2005 : • ATN and prominent tubular cell vacuolization, compatible with drug toxicity. • Mild increase in the number of neutrophils and monocytes in PTC and in rare glomeruli. C4d negative.

6. Received a total of • 5 doses of Thymoglobulin, at 1.5 mg/kg/dose (75 mg), • methylprednisolone pulses • 80 g IVIG • 5 dialysis treatments following which graft function resumed. • It became evident that the donor kidney had suffered severe ATN, compounded by the pre-operative use of (0.1 mg/kg) tacrolimus, as reflected by the prominent tubular cell vacuolization. • Discharged from hospital 3 weeks after surgery, creatinine of 95-100 µmol/l. • Immunosuppressive regimen consisted of tacrolimus 6 mg q12h, MMF 750/500 mg daily and prednisone 10 mg. Tacrolimus tough levels were 9-10 ng/ml.

7. Second biopsy on November 25, 2005 (post-op day 30) because  in creatinine to 114 µmol/L : • possible borderline rejection (Banff t1, i1, v0) • focally diluted tubules with occasional neutrophils • tubular cell cytoplasmic vacuolization • Prompting a course of 3 steroid pulses. • Clinical (dysuria), microbiological (Enterococcus sp. 107/L) and biopsy findings compatible with urinary tract infection, for which she was treated. • We reduced the tacrolimus dose to 3.5 mg q12h by early February 2006 and administered monthly doses of 1 mg/kg Daclizumab, in addition to continued treatment with MMF (750/500 mg daily). She maintained stable tacrolimus trough levels of 3.5-5 ng/ml and creatinine of 75-85 µmol/l.

8. Since February 13(4th month post-transplant) prednisone dose was gradually reduceduntil mid April, to 7.5 and 0 mg on alternate days. • Surveillance biopsy on April 19, 2006: • no acute rejection (t0, i1, v0) • significant chronic allograft nephropathy (Banff ct2, ci2, cv0). • polyomavirus and C4d immunostains were negative. • Based on accumulating data from the literature favoring treatment with sirolimus in the presence of chronic graft changes, we decided to switch to sirolimus concomitantly with her last, sixth, Daclizumab infusion. • She received a loading dose of 12 mg of sirolimus on May 15, 2006, followed by 2 mg bid, along with tacrolimus 2 mg q12h and MMF 750/500 mg. The SRL 12-h trough level was between 6.8 and 8.0 ng/ml. Daily prednisone was resumed at a negotiated dose of 4 mg.

9. Admitted on June 19 with fever and graft swelling, creatinine 105 µmol/l. • Biopsy on June 20, 2006(reviewed here): • severe rejection (Banff t3, i3, v1, consistent with type IIA) with eosinophil-rich infiltrate. • C4d and polyomavirus stains: negative. • Received 3 pulses of IV methylprednisolone, a total of 100 g IVIG and 10 doses of 1.5 mg/kg Thymoglobulin until July 5, when her serum creatinine had stabilized at 80 μmol/l. • She was now on daily 10 mg prednisone, 3/3 mg SRL, 750/500 mg MMF.

10. Subsequently, creatinine rose to 92 μmol/l • Repeat biopsy on July 10, 2006(reviewed here): • grade IB rejection (t3, i3, v0). • C4d and polyomavirus immunostains were negative. • Single dose of Daclizumab and repeat IVIG infusions were given. • Based on external advice, we administered a total of 70 mg of OKT3 between July 13 and 24. • We also stopped MMF and restarted tacrolimus on July 19 at 4 mg q12h along with 3/3 mg SRL. • The creatinine level remained essentially unchanged.

11. OnAugust 3, 2006, the creatinine had risen from 91 to 109 μmol/l. It peaked at 151 μmol/l on Aug 5. Additional findings were: • decreasing peripheral leukocytes (nadir 2.7/nl), • worsening normocytic, non-hemolytic anemia (89 g/l) and mild thrombocytopenia (118/nl) and few schistocytes. • Rebiopsied on August 3, 2006 (reviewed here): • no evidence of thrombotic microangiopathy • rejection slightly improved, still consistent with IB (t3, i2, v0) • negative for C4d and polyomavirus. • mild to moderate patchy interstitial fibrosis. • 80% CD3, 20% for CD20. • Received 3 methylprednisolone pulses + weekly doses of 375 mg/m2 SA Rituximab. Creatinine appeared to stabilize at 112 μmol/l, but  to 131 μmol/l prior to the 4th and final Rituximab dose on August 26.

12. Last biopsy on Sept 7, 2006: • Persistent moderate acute cellular rejection with moderate parenchymal scarring. • No definitive evidence of a second disease process beyond rejection. • Banff scoring: G0 CG0 I3 CI2 T3 CT2 V0 CV1 AH0 MM0 • Since her last biopsy, her serum creatinine continues to creep up, now 160 umol/l.

14. In summary • Post-transplant course is complicated by : • chronic allograft nephropathy • recalcitrant rejection Despite the use of: • methylprednisolone, • Thymoglobulin, • IVIG, • OKT3 lastly Rituximab. • Hematological changes have stabilized, serum transaminases continue to be normal. • Multiple urine and renal samples failed to demonstrate viral changes or bacterial infection. There was a single, unconfirmed low-titer EBV PCR result and no evidence of CMV amplification.