Application of rituximab to hepatitis C-positive, ABO-incompatible renal transplantation

A safety issue has been noted in applying rituximab to renal transplant patients with HCV infection, as a hepatitis C virus (HCV) flare-up and lethal cholestatic hepatitis C occurred in a renal transplant patient treated with rituximab for lymphoproliferative disorder. As double-filtration plasmapheresis (DFPP) and cyclosporine were reported to reduce hepatitis C viremia, we performed ABO-incompatible renal transplantation in two patients with positive HCV RNA by using rituximab, DFPP and cyclosporine-based immunosuppressant. The HCV RNA level was 3.3 x 10(5) IU/mL for Case 1 and 1.2 x 10(3) IU/mL for Case 2 before DFPP. After DFPP and renal transplantation, Case 1 had stable ALT levels and a transient decrease in HCV RNA to 7.9 x 10(4) IU/mL at 1 month followed by a gradual increase to 7.6 x 10(6) at 12 months, but Case 2 had a dramatic and persistent elevation of HCV RNA to 7.7 x 10(6) from 1 week to 12 months accompanied by elevated ALT levels. The serum creatinine levels were 1.5 mg/dL for Case 1 and 1.9 mg/dL for Case 2 at 12 months. Although cholestatic hepatitis C did not occur in our patients, who received rituximab for ABO-incompatible renal transplantation, the antiviral effect of cyclosporine and DFPP did not seem evident.