S4987 Inflammatory Bowel Disease to Renal Transplant: A Case Series of Vedolizumab-Induced Renal Failure

Introduction: Vedolizumab (VDZ), a monoclonal antibody targeting α4B7 integrin, is an effective therapy for ulcerative colitis and Crohn’s disease. It blocks the interaction between α4B7 and MAdCAM-1, inhibiting immune cell migration into the gastrointestinal tract. This case series reports on 2 otherwise healthy patients with inflammatory bowel disease who developed rapidly progressive renal failure requiring renal transplantation following VDZ initiation. Case Description/Methods: Case 1: A 35-year-old woman with stage III chronic kidney disease (CKD) secondary to chronic interstitial nephritis was diagnosed with ileocolonic Crohn’s disease. After her first dose of VDZ therapy she reported fevers, abdominal pain, and nausea. Following her 2nd dose she had similar symptoms and new acute on chronic kidney injury, with a creatinine rise from baseline of 1.6 mg/dL to 3.6 mg/dL. VDZ was discontinued. Despite high dose prednisone, she was diagnosed with end stage renal disease. The patient received a kidney transplant 18 months after her first VDZ dose. Case 2: A 50-year-old woman with ulcerative pancolitis in remission for years on mesalamine was hospitalized with new onset renal failure. Biopsy demonstrated acute interstitial nephritis (AIN) attributed to mesalamine, and she developed CKD with new baseline creatinine of 1.5 mg/dL. Her ulcerative colitis was controlled with oral budesonide for 8 years and discontinued after her disease was in deep remission. One year later, she reported loose stools and started VDZ therapy. Soon after, her renal function declined with creatinine rising to 3.2 mg/dL. She underwent renal biopsy demonstrating acute tubular necrosis, acute interstitial nephritis, arteriolosclerosis, focal glomerulosclerosis, and tubular sclerosis. VDZ was discontinued 8 months after initiation. The patient underwent kidney transplant 1.5 years later. Discussion: AIN is a rare side effect of VDZ therapy. Few case reports have demonstrated biopsy proven AIN following initiation of VDZ, and none have described progressive renal failure requiring transplant after VDZ. The temporal correlation of acute on chronic renal failure following VDZ initiation in these patients implicates this therapy as the primary driver. This series highlights the need for renal function monitoring in patients receiving vedolizumab, particularly those with established CKD. As we engage with novel therapies for inflammatory bowel disease, it is essential to report adverse events to inform a personalized approach to each patient.