*Purpose: The purpose of this study is to identify and characterize infections in abdominal organ transplant recipients related to treatment with eculizumab. Eculizumab (Soliris®) is a monoclonal antibody used to treat atypical hemolytic uremic syndrome (aHUS), which occurs as a result of uncontrolled complement activation. Eculizumab blocks C5, preventing terminal complement activation and membrane attack complex (MAC) formation. There is risk of infection with eculizumab in immunosuppressed patients, specifically the risk of infection caused by encapsulated bacteria, particularly meningococcus, and fungi.

*Methods: This is a retrospective, single-center review of abdominal transplant recipients; liver (LT), intestine (ITx) and multivisceral (MVT), who received at least 1 dose of eculizumab for aHUS or TMA (thrombotic microangiopathies) between 01/01/2012 and 06/01/2018. The primary outcome was development of infection with positive cultures while on eculizumab. Secondary outcomes included incidence of transplant rejection and mortality related to infection or allograft loss.

*Results: 20 patients received eculizumab: 13 ITx/MVT and 7 LT. Eculizumab was started a median of 105 days after transplant. 16/20 patients (80%) had one or more infection while on eculizumab. 15/20 (75%) had at least 1 bacterial infection, 7/20 (35%) patients had an invasive fungal infection, and 13/20 (65%) had viral infections either due to EBV or CMV. 12/20 (60%) had bacteremia or fungemia. No meningococcal infections were identified. The median time to first infection after eculizumab initiation was 19 days [8-75]. Amongst those patients with invasive fungal infections (2 LT, 5 ITx/MVT); 4 had invasive pulmonary Aspergillosis, 3 had invasive infection due to Candida glabrata, and 1 had invasive pulmonary infection due to Acremonium/Paecilomyces species. The median time to fungal infection after starting eculizumab was 38 days [15-148]. Only 1 patient with invasive fungal infection had preceding CMV infection. Mortality rate in patients with invasive fungal infections was 100%. Overall incidence of rejection was 4/20 (20%). The overall survival was 55% (11/20).

*Conclusions: Eculizumab was associated with a high incidence of infections in abdominal SOT patients. Invasive fungal infections were associated with an extremely high mortality, and therefore may warrant consideration for fungal prophylaxis in SOT patients receiving eculizumab. Further studies are needed to evaluate the association between eculizumab and fungal infections in this patient population.

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