D133 - Early Recognition and RNAi-Based Management of Primary Hyperoxaluria Presenting as Delayed Graft Function After Kidney Transplantation

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Author Block: Y. A. Qazi¹, N. Campos², D. Luu², R. Naraghi², ¹Keck Medical Center at USC, Los Angeles, CA, ²Providence St Joseph Hospital, Orange, CA
*Purpose: Oxalate nephropathy has been associated with DGF and Primary Hyperoxaluria (PH) may be an unrecognized etiology predisposing to this association. Early diagnosis is critical as targeted therapies like RNA interference (RNAi) agents—can potentially improve graft outcomes.
*Methods: 47-year-old male who underwent DDKTx 5/2025 and developed DGF . Routine post-transplant evaluation was unrevealing, prompting an allograft biopsy and measurement of plasma/urine oxalate levels. Genetic testing for hyperoxaluria and nephrolithiasis disorders was sent to a reference laboratory. Empiric therapy with Oxalmo® was initiated based on high clinical suspicion for hyperoxaluria. After genetic confirmation, the patient was transitioned to RNAi-based therapy with Rivfloza® (nedosiran). A repeat biopsy done 3 month later showed significant decrease in oxalate deposits.
*Results: Biopsy demonstrated oxalate deposition consistent with oxalate nephropathy. Serial oxalate levels showed a downward trend following therapy initiation. Genetic testing identified a heterozygous pathogenic GRHPR variant, confirming Primary Hyperoxaluria Type 2 (PH2). The patient demonstrated clinical stabilization with improving graft function following dialysis optimization, aggressive hydration, and institution of targeted oxalate-lowering therapy.
*Conclusions: Our case and other recent literature recognize the association of Oxalate Nephropathy with DGF. Routine assessment of oxalate levels in unexplained DGF and early incorporation of genetic testing—particularly in younger candidates with unclear etiology for ESRD—can guide therapy, optimize graft outcomes, and support family counseling. Timely intervention with Oxalate lowering therapies may facilitate recovery of allograft function