The use of sequential living donor kidney and autologous stem cell transplantation for patients with primary (Al) amyloidosis and advanced renal failure

Patients with primary (AL) amyloidosis and renal failure have limited life expectancy on dialysis and face higher risk during autologous stem cell transplantation (ASCT). We have pursued a novel strategy of living donor kidney transplant (KTx) prior to ASCT for these patients. Clinical and laboratory outcomes of all 7 patients accepted for this protocol at Mayo Clinic between Dec 1999 and Feb 2003 were reviewed. Five of the 7 were on dialysis prior to KTx. All 7 patients underwent living donor KTx and experienced good initial graft function. Immunosuppression was tacrolimus (n = 4), cyclosporine (n = 2), or sirolimus (n = 1) in combination with mycophenolate mofetil and prednisone. Five patients subsequently underwent ASCT, 4 with good outcome. For these 4 patients, stem cell harvest was carried out prior to KTx for 3 and after KTx for 1. Average times to neutrophil and platelet engraftment were 15.5 and 23.5 days respectively. The fifth developed progressive hepatic amyloidosis after KTx and was advised against ASCT, died following ASCT elsewhere. Two did not undergo ASCT. One died of a demyelinating disease 4 weeks after KTx. The other has thus far elected not to undergo ASCT and has minimal recurrent disease after 3 years. Living donor KTx followed by ASCT is a feasible approach for AL patients with advanced renal impairment. Prudent patient selection is crucial as KTx will delay ASCT. Stem cell engraftment was not impaired by triple-drug immunosuppression.