Morrison Steven A, Vinson Amanda J
Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada.
Can J Kidney Health Dis. 2024 Oct 21;11:20543581241289191. doi: 10.1177/20543581241289191. eCollection 2024.
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.
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.
Both patients were diagnosed with acute rejection in the setting of reduced immunosuppression and initiation of an ICI.
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.
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.
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.
由于长期免疫抑制，肾移植（KT）受者患恶性肿瘤的风险增加。免疫检查点抑制剂（ICI）的新应用为恶性肿瘤的治疗带来了有前景的进展，但它们的使用增加了KT受者免疫抑制管理的复杂性。本病例报告描述了2例在开始使用ICI后发生急性排斥反应的KT受者，并讨论了恶性肿瘤治疗与充分免疫抑制之间的平衡。
首例患者为一名44岁男性KT受者，诊断为转移性肾细胞癌，在开始使用ICI后6天出现急性肾损伤。第二例患者为一名73岁男性KT受者，诊断为鳞状细胞癌，在开始使用ICI后2周出现急性肾损伤。
两名患者均在免疫抑制降低和开始使用ICI的情况下被诊断为急性排斥反应。
两例患者均接受了更高剂量的类固醇治疗，但移植肾功能未改善。首例患者随后因急性排斥反应的并发症接受了延迟移植肾切除术，而第二例患者未接受肾切除术。
首例患者经历了包括围手术期出血需要多次手术在内的并发症，但最终在血液透析中稳定下来，并对ICI表现出持久反应。第二例患者在ICI治疗后仍依赖透析，并因移植肾并发症再次入院，最终死亡。
本研究强调了管理诊断为恶性肿瘤并接受ICI治疗的KT受者的复杂性。为治疗恶性肿瘤而降低免疫抑制与预防移植肾排斥反应之间的平衡是一项重大挑战。关键考虑因素包括急性移植肾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以制定管理该患者群体的循证指南的必要性。此外，本研究中的患者观点强调了仔细进行风险效益分析以及治疗决策对以患者为中心的结局的影响的重要性。
