# Combined standard immunosuppression and immune checkpoint inhibition for BKPyV+ metastatic renal cell carcinoma of the graft in a kidney transplant recipient with chronic rejection: a case report

## TL;DR

A kidney transplant recipient with a rare cancer was treated with immunotherapy while continuing immunosuppression, achieving cancer remission despite kidney failure.

## Contribution

First reported case of treating metastatic BKPyV+ renal cell carcinoma in a transplant recipient with ICIs and ongoing immunosuppression.

## Key findings

- ICIs ipilimumab and nivolumab achieved sustained partial remission in a dual-kidney transplant recipient.
- Continued immunosuppression prevented acute rejection and graft intolerance despite ICI-induced kidney failure.
- Patient remained on dialysis and ICIs for 17 months without needing graft removal.

## Abstract

We report on the first case of a dual-kidney transplant recipient diagnosed with a metastatic BK polyomavirus-positive clear renal cell carcinoma with sarcomatoid features, which caused extensive vena cava thrombosis. The patient was successfully treated with the immune checkpoint inhibitors (ICIs) ipilimumab plus nivolumab and continued immunosuppression with tacrolimus, mycophenolate, and steroids. He received ICIs despite the presence of graft dysfunction due to transplant glomerulopathy. As expected, the ICI treatment caused a progressive but asymptomatic decline of the graft function, which resulted in end-stage kidney disease. However, continuation of a full immunosuppression prevented acute rejection, graft intolerance syndrome episodes, or dual graft nephrectomy, which enabled the patient to successfully continue ICIs while on dialysis and to achieve sustained partial remission at the 17-month follow-up.