Choice of Induction in the Era of Single-Antigen Bead Testing: An Idiosyncratic Case Report

Use of induction therapy after kidney transplant is based on immunologic risk status, but accurate assessment of risk in the era of advanced immunologic testing can be complex. Here, we describe the case of a young kidney recipient who had a Castleman disease, often regarded as a benign lymphoma. Our patient, a white male patient with Castleman disease, underwent a first kidney transplant with rabbit antithymocyte globulin induction but returned to dialysis after primary nonfunction occurred. A second donor became available who shared 3 class I HLA antigens with the first donor, but only low-level isolated donor-specific antibodies toward HLA-Cw were detected (mean fluorescence intensity < 1000). After consideration by clinicians, the patient received a second transplant and was again given rabbit antithymocyte globulin induction (total dose 6 mg/kg). Graft biopsy at month 3 showed no evidence of microvascular inflammation, and the patient was C4d negative. At last follow-up (18 mo), serum creatinine level was 11 mg/dL and Castleman disease remained quiescent. In this challenging case, after weighing various factors concerning immunologic risk status and risk for posttransplant lymphoproliferative disease in the presence of Castleman disease, induction with rabbit antithymocyte globulin appeared to be the appropriate option. Patients with end-stage renal disease and quiescent Castleman disease should receive induction therapy, with close monitoring.