*Purpose: Graft-versus-host disease (GvHD) is an uncommon but often fatal complication following solid organ transplantation. It occurs when immunocompetent donor T cells are transferred to the recipient from within the graft. Most commonly encountered after small bowel and liver transplants, secondary to lymphoid tissue content, few cases have been identified following kidney-pancreas transplant.

*Methods: A retrospective case review was performed to evaluate clinical presentation, treatment and response timelines, chimerism analysis, and histologic findings of gastrointestinal and bone marrow biopsies in a rare case of GvHD following simultaneous kidney-pancreas (SKP) transplant.

*Results: A 38-year-old woman with past medical history of end-stage renal disease secondary to type 1 diabetes mellitus received an complicated SKP transplant. Fevers, chills, abdominal pain, and diarrhea developed one-month post-transplant. An infectious cause work up was negative. Chimeric studies displayed 23% donor T-cells. A gastrointestinal biopsy was highly suspicious for GvHD. She was treated with intravenous steroids, ruxolitinib, and extracorporeal photopheresis. Despite these interventions, chimeric studies showed a rising proportion of donor T-cells. At 6 weeks post-transplant, T cells were reported as 100% donor composition and the patient exhibited a diffuse rash. A bone marrow biopsy revealed markedly hypocellular marrow. The patient was transferred to an outside hospital for consideration of a bone marrow transplant for definitive treatment of GvHD. The patient then developed a persistent bacteremia with multi-drug resistance and Epstein Barr viremia. Rituximab was initiated for post-transplant lymphoproliferative disorder. She was transferred back to our institution after being deemed ineligible for a bone marrow transplant secondary to multiple opportunistic infections. Hospice care was initiated and the patient expired shortly thereafter.

*Conclusions: This case details the clinical and pathologic findings associated with a rare case of fatal graft-versus-host disease following SKP transplant. While this diagnosis is rare in the field of solid organ transplant, particularly in SKP scenarios, early recognition and intervention may permit successful treatments in future cases.

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