Desensibilização em transplante renal – experiência da PUCRS (relato de caso) HOSPITAL SÃO LUCAS DA PUCRS SERVIÇO DE NEFROLOGIA 2012 David Saitovitch.

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Presentation transcript:

Desensibilização em transplante renal – experiência da PUCRS (relato de caso) HOSPITAL SÃO LUCAS DA PUCRS SERVIÇO DE NEFROLOGIA 2012 David Saitovitch

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation IgA Nephropathy

G.C.V.J., 49-year-old, Brazilian, caucasian, female Case presentation IgA Nephropathy dialysis since 07/2000

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation IgA Nephropathy 2 pregnancies, 10 blood transfusions, 1st kidney tx 06/2003 dialysis since 07/2000

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation IgA Nephropathy Primary non-function pregnancies, 10 blood transfusions, 1st kidney tx 06/2003 dialysis since 07/2000

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation IgA Nephropathy Primary non-function.... Etiology???? 2 pregnancies, 10 blood transfusions, 1st kidney tx 06/2003 dialysis since 07/2000

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Waiting list

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Waiting list CMs

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Waiting list CMs → +

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Waiting list CMs → + PRA (CDC) → >90%

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Waiting list vascular access...

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Waiting list vascular access... dificult!

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Peritoneal dialysis 03/2006

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Peritoneal dialysis 03/2006 Peritonitis

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation ultrafiltration... failure! Peritoneal dialysis 03/2006

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis 03/2008

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation vascular access... dificult! Hemodialysis 03/2008

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation vascular access... dificult! Priority on the waiting list (2009) ! Hemodialysis 03/2008

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list!

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! ↑ CMs

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! ↑ CMs → +

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! ↑ CMs →

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! PRA (CDC) → >95%

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! PRA (Flow) → >95%

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! Desensitization protocol

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! Desensitization protocol ivig

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! Desensitization protocol ivig 2g/Kg (monthly) 2010

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! Desensitization protocol ivig 2g/Kg (monthly) 2010 CMs → +

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! Desensitization protocol ivig 2g/Kg (monthly) 2010 CMs → + PRA...??

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! Desensitization protocol PP/ivig 0.1g/Kg Jan 2011

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Hemodialysis Priority on the waiting list! Desensitization protocol PP/ivig 0.1g/Kg Jan 2011 Deceased donor allograft 21/02/11

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11ABDRRecipient2,2435,6513,16 Donor 2, - 51,5713,17

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11ABDRRecipient2,2435,6513,16 Donor 2, - 51,5713,17

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11ABDRRecipient2,2435,6513,16 Donor 2, - 51,5713,17

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11ABDRRecipient2,2435,6513,16 Donor 2, - 51,5713,17 DQ2

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11 CDC Cross-match (-)

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11 CDC Cross-match (-) Flow Cross-match (+)

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11 CDC Cross-match (-) Flow Cross-match (+)

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11 Cold ischemia – 32 h Anastomosis time – 40 min.

G.C.V.J., 49-year-old Brazilian, Caucasian female Case presentation Deceased donor allograft 21/Feb/11 Immunosuppression Thymo (1,5mg/kg) Tac MMF Prednisone PP/ivig

(mg/dL) (days) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female  HD (Tac + MMF + Pred) PP/IVIG 3x/week

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

B*57 14/02/11 MFI= /02/11 MFI= /03/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI=12093 DQ*2

B*57 14/02/11 MFI= /02/11 MFI= /03/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI=12093 DQ*2

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

B*57 14/02/11 MFI= /02/11 MFI= /03/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI=12093 DQ*2

B*57 14/02/11 MFI= /02/11 MFI= /03/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI=12093 DQ*2

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)  graft biopsy

C4d+

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)  Tac dose (blood levels 13 ng/ml)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)  bortezomib 1st

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)  Tac dose (blood levels 16.3 ng/ml)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)  bortezomib 2nd

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)  bortezomib 3rd

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)  bortezomib 4th

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

B*57 14/02/11 MFI= /02/11 MFI= /03/11 MFI=8694 DQ*2 14/02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI=4218

B*57 14/02/11 MFI= /02/11 MFI= /03/11 MFI=8694 DQ*2 14/02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI=4218

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred)

(mg/dL) (days)  Thymoglobuline Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female HD PP/IVIG 3x/week PP/IVIG 3x/week (Tac + MMF + Pred) DISCHARGED

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred)

B*57 DQ*2 14/02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /04/11 MFI= /04/11 MFI=2141

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred)

14/02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /04/11 MFI= /05/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /04/11 MFI= /05/11 MFI= /05/11 MFI= /05/11 MFI=6038 B*57DQ*2

14/02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /04/11 MFI= /05/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /04/11 MFI= /05/11 MFI= /05/11 MFI= /05/11 MFI=6038 B*57DQ*2

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred)

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred) APN

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred) APN - Cefepime

14/02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /04/11 MFI= /05/11 MFI= /05/11 MFI= /08/11 MFI= /02/11 MFI= /02/11 MFI= /03/11 MFI= /03/11 MFI= /03/11 MFI= /04/11 MFI= /05/11 MFI= /05/11 MFI= /08/11 MFI=1457 DQ*2B*57

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred)

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred)

(mg/dL) (mo) Case presentation G.C.V.J., 49-year-old Brazilian, Caucasian female (Tac + MMF + Pred) Acknowledgements to Dr. Jorge M. Neumann et al. Laboratorio de Imunologia de Transplantes – Hospital Don Vicente Scherer