title: Eculizumab, bortezomib and kidney paired donation facilitate transplantation of a highly sensitized patient without vascular access.
abstract: A 43-year-old patient with end-stage renal disease, a hypercoagulable condition and 100% panel reactive antibody was transferred to our institution with loss of hemodialysis access and thrombosis of the superior and inferior vena cava, bilateral iliac and femoral veins. A transhepatic catheter was placed but became infected. Access through a stented subclavian into a dilated azygos vein was established. Desensitization with two cycles of bortezomib was undertaken after anti-CD20 and IVIg were given. A flow-positive, cytotoxic-negative cross-match live-donor kidney at the end of an eight-way multi-institution domino chain became available, with a favorable genotype for this patient with impending total loss of a dialysis option. The patient received three pretransplant plasmapheresis treatments. Intraoperatively, the superior mesenteric vein was the only identifiable patent target for venous drainage. Eculizumab was administered postoperatively in the setting of antibody-mediated rejection and an inability to perform additional plasmapheresis. Creatinine remains normal at 6 months posttransplant and flow cross-match is negative. In this report, we describe the combined use of new agents (bortezomib and eculizumab) and modalities (nontraditional vascular access, splanchnic drainage of graft and domino paired donation) in a patient who would have died without transplantation.
authors.affiliation: Division of Transplant Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: B E
authors.initials: BE
authors.lastname: Lonze
authors.forename: N N
authors.initials: NN
authors.lastname: Dagher
authors.forename: C E
authors.initials: CE
authors.lastname: Simpkins
authors.forename: J E
authors.initials: JE
authors.lastname: Locke
authors.forename: A L
authors.initials: AL
authors.lastname: Singer
authors.forename: D L
authors.initials: DL
authors.lastname: Segev
authors.forename: A A
authors.initials: AA
authors.lastname: Zachary
authors.forename: R A
authors.initials: RA
authors.lastname: Montgomery
mesh_terms: D000328:Adult; D000906:Antibodies / Q000097:blood / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized; D018951:Antigens, CD20 / Q000276:immunology; D001897:Boronic Acids / Q000627:therapeutic use*; D000069286:Bortezomib; D002408:Catheters, Indwelling; D003404:Creatinine / Q000097:blood; D003888:Desensitization, Immunologic / Q000379:methods; D004322:Drainage; D004359:Drug Therapy, Combination; D005260:Female; D005268:Femoral Vein; D006801:Humans; D007084:Iliac Vein; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007676:Kidney Failure, Chronic / Q000097:blood / Q000150:complications / Q000276:immunology / Q000628:therapy*; D016030:Kidney Transplantation; D019520:Living Donors; D010956:Plasmapheresis; D011480:Protease Inhibitors / Q000627:therapeutic use*; D011719:Pyrazines / Q000627:therapeutic use*; D013152:Splanchnic Circulation; D035703:Therapies, Investigational; D009927:Tissue and Organ Procurement / Q000379:methods*; D014682:Vena Cava, Inferior; D014683:Vena Cava, Superior; D020246:Venous Thrombosis / Q000150:complications
chemical_list: D000906:Antibodies; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018951:Antigens, CD20; D001897:Boronic Acids; D016756:Immunoglobulins, Intravenous; D011480:Protease Inhibitors; D011719:Pyrazines; D000069286:Bortezomib; C481642:eculizumab; D003404:Creatinine