Dosing Eculizumab for Antibody-Mediated Rejection in Kidney Transplantation: A Case Report

Severe antibody-mediated rejection (AMR) of a blood type-incompatible (ABOi) living donor kidney transplantation (LDKT) can lead to graft failure, and aggressive therapies, such as the anticomplement antibody eculizumab, are often used to rescue the affected graft. Eculizumab therapy can be crippling financially. Current literature suggests a wide variation in the amount and timing of eculizumab given as rescue therapy in the setting of AMR. Herein we describe a limited-eculizumab regimen in the setting of severe AMR that is both clinically and cost effective. Treatment included escalation in plasmapheresis and intravenous immunoglobulin (PP/IVIg) and eculizumab. Eculizumab therapy was discontinued at the first sign of clinical improvement (2-fold decrease in anti-ABO titer and stabilization of serum creatinine). The current standard of care is to redose eculizumab after any PP treatment, and, in some series, continue with maintenance eculizumab doses. In these 2 cases, discontinuing eculizumab therapy upon observed clinical improvement saved 6 unnecessary doses at a cost of $90,000. Both patients have more than 1 year of follow-up and functioning allografts. Although this is a small and limited study, we suggest that a dosing regimen of eculizumab similar to that presented here may be effective in rescuing a graft following AMR while simultaneously limiting cost.