Nursing and Allied Health Symposium

Category: Nursing & Allied Health Symposium

The use of a BCMA-directed bispecific antibody to treat relapsed myeloma in a liver transplant patient receiving continuous T-cell immunosuppression and concurrent hemodialysis

(NSP-01) The Use of a BCMA-directed Bispecific Antibody to Treat Relapsed Myeloma in a Liver Transplant Patient Receiving Continuous T-cell Immunosuppression and Concurrent Hemodialysis

Thursday, September 18, 2025

Kevin Brigle, PhD, NP

Oncology Nurse Practitioner
Massey Comprehensive Cancer Center, Virginia Commonwealth University

Introduction: Bispecific T-cell Engagers bind to CD3 receptors on T cells and an antigen on the surface of tumor cells. This interaction activates T cells, stimulating an immune attack leading to destruction of malignant cells. Properly functioning T cells play a crucial role in this pathway and inhibition of T cell activity would be expected to blunt the response of these agents. There is no published data concerning the use of these agents in patients having had a solid organ transplant who are receiving immunosuppression and little data regarding their use in patients requiring hemodialysis.

Methods: Case Study

Results: We present the case of a 75-year-old male status post deceased donor liver transplant Jan 1998. He subsequently developed ESRD secondary to sirolimus and cyclosporin toxicity necessitating renal transplantation (deceased donor) in Sept 2002. Upon routine monitoring, in Mar 2004 he was noted to have an IgA lambda monoclonal protein present on UPEP-IFE. Oncology workup noted this to be a low risk MGUS and he was monitored every 6 months. In Mar 2010 he developed worsening renal function with renal biopsy noting focal segmental glomerulosclerosis and no evidence of rejection or light chain deposition. Following 12 years of monitoring, in July 2016 he experienced rapid progression of MGUS to myeloma noted by an elevation of serum lambda light chains to 7793 mg/L with an involved-uninvolved ratio of 371. Bone marrow biopsy (BMBx) noted 20% lambda-restricted plasma cells with normal FISH. He began treatment with lenalidomide-bortezomib-dexamethasone (dex) followed by bortezomib maintenance. Over the next 8 years, he experienced two relapses which were treated with daratumumab-dex and carfilzomib-daratumumab-dex. During this time frame he also developed new onset A-fib and CHF resulting in acute kidney injury and the requirement for hemodialysis 3 times weekly. At his 3^rd relapse in Jan 2024, PET scan was unremarkable but BMBx noted 10-15% lambda-restricted plasma cells now with multiple (9) new cytogenetic abnormalities including amp 1q (9%). He initiated teclistamab Mar 2024, continuing full dose T-cell immunosuppression with sirolimus and cyclosporin. His dialysis sessions occurred on the day prior to receiving teclistamab, then 2 days and 4 days following. He achieved a rapid normalization of serum lambda light chains within 3 weeks of starting therapy. Following 5 months of weekly therapy, BMBx July 2024 noted an MRD negative CR (normal FISH) and teclistamab was converted to every other week (cycle 7). Following 14 months of therapy, BMBx May 2025 noted a continued MRD negative CR (normal FISH) and teclistamab was converted to monthly dosing.

Conclusions:

This case supports the efficacy and safety of teclistamab in a patient receiving T-cell immunosuppression following solid organ transplant, even when complicated by the necessity for concurrent dialysis.