Long-Term Outcome of a Deceased Donor Kidney Transplant in a Patient with Active Chronic Lymphocytic Leukemia at Time of Transplantation

Introduction: While active malignancy is often considered a contraindication to kidney transplantation, certain malignancies have an increased survival with medication advancements. Chronic lymphocytic leukemia (CLL) is such a disease with an 88% 5-year survival and median survival of nearly 10 years. Concerns for organ transplantation in patients with CLL include risk of immunosuppression on disease progression, potential leukemic infiltration of allograft, and increased risk of infection. Transplant experience in patients with CLL is limited. Published experiences report high rates of graft failure and mortality and no long-term follow-up data. We present a patient with CLL treated with a Bruton Tyrosine Kinase inhibitor, ibrutinib, who underwent successful kidney transplant with excellent long-term outcome. Case Description: A 50-year-old male was diagnosed with CLL/small lymphocytic lymphoma Rai stage 0 with favorable genetics and was initially treated with monitoring approach. Due to CLL progression and kidney function decline, cyclophosphamide and rituximab were initiated. Kidney biopsy revealed IgA Nephropathy with CLL involvement characterized by lymphocytic interstitial infiltrate. He progressed to end-stage kidney disease and completed two years of rituximab followed by maintenance ibrutinib. Prior to transplant, ibrutinib was stopped with concern of increased bleeding risk. He underwent successful deceased donor kidney transplantation with basiliximab induction and maintenance immunosuppression with tacrolimus, mycophenolate sodium (MPS), and prednisone. Three years post-transplant, progression of CLL developed with worsening lymphadenopathy and lymphocytosis. MPS and tacrolimus doses were reduced. Ibrutinib was resumed and his CLL responded to treatment with improvement in lymphocytosis. Eight years from transplant, serum creatinine is 1.16, without infectious complication or adverse allograft injury related to CLL. Discussion: While patients with CLL have frequently been excluded from kidney transplant consideration, newer therapies and improved understanding of favorable prognostic markers may allow for safe kidney transplantation in lower risk patients. This case demonstrates potential longevity following transplant with appropriate treatment and immunosuppression adjustments.