Successful kidney transplantation in a patient with pre-existing chronic myeloid leukemia treated with imatinib

Chronic Myeloid Leukemia in Renal Transplantation Patients in the Era of Tyrosine Kinase Inhibitors: A Case Report and Review of the Literature

Lifelong immunosuppression, cytotoxic effects of some immunosuppressive drugs, and opportunistic oncogenic viruses increase malignancy risks in solid organ recipients. The risk of myeloid neoplasms including chronic myeloid leukemia (CML) is also increased in this patient population. Tyrosine kinase inhibitors (TKIs), the key element of CML therapy, should be used cautiously in transplantation patients as they may interact with calcineurin inhibitors. With this report, a 63-year-old female kidney transplant recipient who developed CML 9 years after kidney transplantation is presented. CML in this patient was treated with a slightly reduced dose of imatinib (300 mg) due to concerns of adverse events including its interaction with tacrolimus. Deep molecular response (DMR) was achieved at 12 months under imatinib treatment. The patient is still in DMR after 30 months of follow-up, and she did not experience any adverse events or acute rejection episodes. CML and the use of TKIs in kidney transplant patients have been discussed with an extensive literature review. In this patient population, TKIs are generally well tolerated with achievement of treatment responses and good prognosis. Graft functions are also well maintained as long as drug interactions are monitored.

A Case Report of Kidney Transplantation in a Patient With Pre-existing Chronic Myeloid Leukemia: The Role of Achieving Molecular Response and Treatment-Free Remission

BACKGROUND

Treatment-free remission (TFR) in chronic myeloid leukemia (CML) is achieved when a patient who has discontinued tyrosine-kinase inhibitor treatment sustains major molecular response (MMR) and does not require restarting therapy. The feasibility of kidney transplantation (KT), and achieving TFR post-transplantation in patients with a pre-existing CML, are currently not well-studied.

METHODS

We describe the clinical course of a 39-year-old Filipino woman with IgA nephropathy who developed CML during treatment. She received nilotinib 600 mg daily and was able to achieve MMR after 5 months. Eight years later, the patient sustained MMR; however, she ultimately underwent KT due to advancing kidney disease. Before the transplant, she was able to achieve deep molecular response. In anticipation of possible drug-to-drug interaction of nilotinib with tacrolimus and everolimus, a shared decision was made to discontinue nilotinib despite not fulfilling the criteria for TFR. Twelve months post-transplant, the patient remains in MMR without nilotinib. Good renal allograft function was maintained, and there were no signs of allograft rejection.

CONCLUSIONS

Attempting TFR may be feasible after KT in patients with low-risk chronic phase CML especially if good molecular response is obtained before the transplant. Data regarding the length at which TFR can be maintained after KT is still yet to be determined. In this regard, low-risk chronic phase CML in good disease control may not be considered a contraindication to KT.

A Case Report of Successful Kidney Transplantation in a Patient With Chronic Myelogenous Leukemia (CML) Who Has Been in Remission for 15 Years on Imatinib

For chronic myeloid leukemia (CML), a Philadelphia chromosome-positive myeloproliferative neoplasm, the introduction of tyrosine kinase inhibitors has transformed CML from a lethal disease into a manageable chronic disease with a close-to-normal life expectancy. Active malignancy is an absolute contraindication to kidney transplantation. However, it is controversial whether kidney transplantation can be safely performed in patients with a history of CML who are in remission. We describe the clinical course of a 64-year-old male patient with chronic kidney disease from diabetic nephropathy (DMN) who underwent living donor kidney transplantation. The patient was diagnosed with CML 15 years ago and promptly achieved cytogenetic and molecular biological remission after starting imatinib. After that, he continued imatinib treatment for 15 years and was in remission, but his chronic kidney disease from DMN gradually worsened. A preemptive living donor kidney transplant was performed in July 2020. Imatinib for CML was discontinued because the patient maintained deep molecular remission (DMR) of major molecular response for more than 15 years before kidney transplantation. After kidney transplantation, the transplanted kidney function remained good at approximate serum creatinine levels of 1.1 mg/dL without histopathologic rejection, and the 3 monthly BCR-ABL1 measurement results were negative and are in progress. Thus, he continues to maintain treatment-free remission status without imatinib for 26 months after renal transplantation. In conclusion, this result suggests that CML with long-lasting DMR on imatinib therapy can be considered an inactive malignancy and therefore a relative indication for kidney transplantation.

Successful kidney transplantation in a patient with pre-existing chronic myeloid leukemia treated with imatinib

Active malignancy is an absolute contraindication to kidney transplantation. As for chronic myeloid leukemia (CML), a Philadelphia chromosome-positive myeloproliferative neoplasm, the introduction of tyrosine kinase inhibitors has transformed CML from a lethal into a manageable chronic disease with a close-to-normal life expectancy. To date it is unknown whether kidney transplantation can be safely performed in patients with pre-existing CML. We describe the clinical course of a 57-year-old male patient with chronic kidney disease caused by reflux nephropathy. This patient had undergone first kidney transplantation 20 years earlier and had again been on chronic hemodialysis for 6 years when CML was diagnosed. First-line therapy with 400 mg imatinib daily was well tolerated and induced an optimal cytogenetic and molecular response 3 months after initiation. One and a half years after CML diagnosis, a second kidney transplantation from a deceased donor was performed. Immunosuppression included basiliximab, tacrolimus, mycophenolate mofetil, and corticosteroids. Currently, 2 years posttransplant, renal allograft function is stable (serum creatinine 1.09 mg/dL, estimated glomerular filtration rate 75 mL/min per 1.73 m² ), and CML remains in deep molecular remission with imatinib. Imatinib-treated CML in deep molecular remission could be regarded as inactive malignancy and may therefore not be viewed as an absolute contraindication to kidney transplantation.