Challenges in Lung Re-Transplantation Following Antibody-Mediated Rejection

Abstract

<h3>Introduction</h3> Despite lung re-transplantation is becoming more frequent, it continues to present several challenges in regards to the management of immunosuppression and infectious risks. We present a case of invasive aspergillosis that highlights the risks associated with increasing immunosuppression after re-transplantation due to antibody-mediated rejection (AMR). <h3>Case Report</h3> Patient is 30 years-old male who underwent primary bilateral lung transplant in December 2016 due to H1N1 Influenza and respiratory failure. His immunosuppression regimen included tacrolimus, prednisone and mycophenolate mofetil (MMF). In June 2018, the patient developed evidence of a significant lung function decline, multiple de novo donor-specific antibodies, including DR17 and DQ2, and acute cellular rejection along with endarteritis on lung biopsy. His initial AMR therapy protocol included intravenous immunoglobulin (IVIG), plasmapheresis, rabbit anti-thymocyte globulin and carfilzomib. Due to the persistence of circulating DSAs and lung function decline, he received also rituximab and monthly belatacept. Eventually, the patient underwent re-transplantation due to chronic lung allograft dysfunction in June 2019. His immunosuppression included tacrolimus, prednisone, MMF, IVIG and belatacept. In November 2019, the patient developed headache, blurry vision and seizure. He was found to have a left parietal lobe abscess requiring resection (figure 1A). Pathology and cultures confirmed the presence of <i>Aspergillus fumigatus</i>. Belatacept and MMF were held. He was treated successfully for 12 months with voriconazole with resolution of symptoms and improved brain imaging (figure 1B). <h3>Summary</h3> The management of immunosuppression in the setting of AMR and re-transplantaion poses several challenges. However, lung re-transplantation remains an ethically justified measures in highly selected patients.