Case presentations on two patients who received bortezomib for antibody mediated rejection at BIDMC

We present two patients with high levels of donor specific antibodies and C4d deposition after treatment for antibody mediated rejection with standard plasmapheresis based therapy. Both patients were given a combination of multiple courses of bortezomib (each course consisted of four doses over 2 weeks) and more plasmapheresis with maintenance immunosuppression therapy. The first patient had 4 donor specific anti-HLA antibodies (DSAs) (of which 1 was against class 1 HLA). After bortezomib therapy, the class 1 antibody did disappear and one of the class 2 antibodies went to below an MFI of 4,000. However, the other 2 DSAs remained strong and she progressed to needing dialysis therapy. The second patient had no change in his strong DSA or in his biopsy findings but his creatinine has remained stable throughout the entire course, without deterioration or improvement. In summary, we saw very little decline in DSA profile and no biopsy improvement in 2 patients treated with bortezomib as salvage therapy for ongoing antibody mediated rejection. It is possible that initiation of bortezomib earlier for these patients with chronic antibody mediated rejection would have proven more effective in eliminating DSA and improving biopsy findings. However, our limited experience suggests that as salvage therapy for ongoing antibody mediated rejection, bortezomib therapy is not useful.