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Please prepare and upload your E-Poster no later than March 14, 2026 11.59PM CET. After this date, you will no longer be able to prepare and upload your E-poster and it will not be displayed and accessible on the congress website.
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Abstract titles should be brief and reflect the content of the abstract.
Kidney retransplantation represents one of the most challenging situations in transplantation medicine, with heightened immunologic, infectious, and technical risks. In developing countries, these challenges are amplified by limitations in laboratory support and immunologic monitoring. Cytomegalovirus (CMV) reactivation and antibody-mediated injury remain major causes of graft dysfunction in sensitized patients. This report presents a successful second kidney transplantation performed in Indonesia for a CMV-seropositive male with biopsy-proven IgA nephropathy, illustrating the feasibility of complex immunologic management under resource-constrained conditions.
A 41-year-old male with end-stage renal disease due to primary IgA nephropathy underwent his second kidney transplantation in September 2024 after the first graft failure in 2018. Both donor and recipient were CMV IgG-reactive and IgM-non-reactive, with a negative crossmatch result. Pre-transplant evaluation showed serum creatinine 6.4 mg/dl, eGFR 10.5 ml/min/1.73 m², hemoglobin 8.7 g/dl, and baseline tacrolimus trough 1.2 ng/ml. A high-risk desensitization regimen was applied, consisting of three sessions of therapeutic plasma exchange (TPE) alternated with plasmapheresis, intravenous immunoglobulin (IVIG) 12.5 g per session (total 50 g), a single rituximab dose 500 mg IV, and 10 units of cryoprecipitate. Induction therapy included basiliximab 20 mg IV and methylprednisolone 500 mg IV, tapered postoperatively to 16 mg/day. Maintenance therapy comprised tacrolimus 8–10 mg/day (target trough 5–8 ng/ml), mycophenolate sodium 720 mg twice daily, and methylprednisolone 8 mg/day. Prophylaxis included valganciclovir, cotrimoxazole, and nystatin.
The procedure was uneventful, with warm ischemic time 31 minutes and cold ischemic time 27 minutes, followed by immediate diuresis (700 ml intraoperatively). Serum creatinine declined from 6.4 mg/dl pre-transplant to 1.1 mg/dl within five days (eGFR 114 ml/min/1.73 m²), indicating excellent early graft recovery. Intraoperative allograft biopsy demonstrated weak linear C4d staining in peritubular capillaries, suggesting minimal complement activation without rejection. Tacrolimus trough levels stabilized at 5.7–8.2 ng/ml. On postoperative week 3, CMV DNAemia (3.48 × 10³ copies/ml) was detected and successfully treated with valganciclovir 900 mg twice daily for three months. No further viral reactivation occurred. Hemoglobin increased to 11.4 g/dl, and the patient maintained stable renal function through six months of follow-up. This case demonstrates that even under limited-resource settings, the combination of TPE–IVIG–rituximab desensitization, optimized tacrolimus dosing, and extended CMV prophylaxis can effectively manage immunologic and infectious risks, resulting in successful graft function.
High-risk kidney retransplantation in CMV-seropositive patients can be safely performed in developing countries when guided by structured immunomodulation, vigilant infection control, and multidisciplinary coordination. This case emphasizes that complex transplant care and excellent graft survival remain achievable despite limited facilities through adaptive and collaborative management strategies.
