Graft Dysfunction with Negative Biopsy - A Case of AT1R Antibody Mediated Rejection Following COVID-19 Infection
Document Type
Conference Proceeding
Publication Date
4-2026
Publication Title
Journal of Heart and Lung Transplantation
Abstract
Introduction: We report a case of biopsy-negative antibody-mediated rejection (AMR) with positive anti-angiotensin II type 1 receptor (AT1R) antibodies, occurring 5 months post-orthotopic heart transplant (OHT), who presented with severe biventricular dysfunction following COVID-19 infection and was successfully treated with a rejection protocol.
Case Report: A 65-year-old male with a history of CKD 3a presented 5 months post-OHT with 2-3 weeks of dyspnea on exertion, fatigue, and generalized weakness. Symptoms began after a COVID-19 infection and failed to improve. He presented for a scheduled endomyocardial biopsy as well as right and left heart catheterization. Coronary angiography revealed normal coronaries, but markedly elevated filling pressures (RA 16 mmHg, RVEDP 17 mmHg, PA 39/23 mmHg, mean 30 mmHg, PCWP 22 mmHg) and reduced cardiac output (thermodilution CO 2.56 L/min, CI 1.36 L/min/m²). Echocardiography showed increased LV wall thickness with LVEF ~35%, severe RV dilation, and severely reduced RV systolic function. Given suspected rejection, the patient was started on plasmapheresis, IVIG, and high-dose methylprednisolone. The course was complicated by AKI on CKD requiring CRRT, as well as vasopressor and inotrope support. Biopsy returned negative for rejection; however, testing revealed AT1R non-HLA donor-specific antibodies. Rituximab was added to complete treatment. The patient experienced significant symptomatic improvement, and repeat echocardiogram demonstrated normalization of LVEF with mild to moderate RV dysfunction.
Summary: This case highlights biopsy-negative AMR associated with AT1R antibodies, potentially triggered by post COVID-19 renin-angiotensin system dysregulation. Prompt recognition and initiation of rejection therapy led to substantial recovery of cardiac function.
Volume
45
Issue
5 Suppl
First Page
441
Last Page
441
Recommended Citation
Yavari M, Rich L, Zampierollo-Jaramillo G, Jani M, Grayburn R, Lee S. Graft dysfunction with negative biopsy -A case of AT1R antibody mediated rejection following COVID-19 infection. J Heart Lung Transplant. 2026;45(5):441. doi: 10.1016/j.healun.2026.02.953.
DOI
10.1016/j.healun.2026.02.953
ISSN
1053-2498
Comments
Annual Meeting and Scientific Sessions of the International Society for Heart and Lung Transplantation (ISHLT), Apr 22-26, 2026, Toronto, Canada