Ofatumumab and Tocilizumab Desensitization in a Highly Sensitized Recipient: A Case Report

Abstract

<h3>Introduction</h3> Sensitization is a challenge in heart transplant recipients, often increasing wait time and decreasing access to acceptable organs. We present a case of a highly sensitized 47-year-old female listed for re-do heart and kidney transplant who was desensitized utilizing ofatumumab and tocilizumab. <h3>Case Report</h3> The patient received her first heart transplant in 1992 (induction muromonab-CD3) for viral cardiomyopathy at an outside hospital; in 2015 she was treated for antibody mediated rejection with plasma exchange (PLEX), intravenous immunoglobulin (IVIG), and bortezomib. She later developed cardiac allograft vasculopathy. In 2018 she was brought to our center with cardiogenic shock and worsening renal function, required dual inotropic support, and evaluated and listed for a re-do heart and kidney transplant. Her peak PRA was 90% with several class I and II antibodies. She underwent desensitization therapy with PLEX, IVIG (2 g/kg), ofatumumab (1 dose), and monthly tocilizumab (3 doses). No adverse drug events were reported during therapy. Her PRA remained persistently ∼90%; MFI trends of her antibodies are presented in Figure 1. After her 3^rd tocilizumab dose she received an offer which was crossmatch negative and no pre-existing antibodies. She received basiliximab induction and maintenance immunosuppression of tacrolimus, mycophenolate, and prednisone. During the 1 year follow-up post-transplant, she had excellent graft function with ejection fraction >60%, serum creatinine <1.2 mg/dL and no episodes of rejection. Tacrolimus levels remained between 5-13 mcg/ml. Post-transplant infections included BK viremia with persistent PCR levels between 600-1500 copies/mL. <h3>Summary</h3> Desensitization with ofatumumab and tocilizumab resulted in successful heart and kidney transplantation. Although PRA and MFI of pre-existing antibodies were not significantly altered, this regimen may have been helpful in reducing de novo donor specific antibodies and preventing acute rejection post-transplant.