Believing in the Nobel Prize: Long-term Success After HLA-Identical Kidney Transplantation in 3 Monozygotic Twins Without any Induction or Maintenance Immunosuppression

Background: Kidney transplantation between HLA-identical monozygotic twins offers a unique chance for long-term graft survival without immunosuppression. Although favorable outcomes after withdrawal of maintenance immunosuppression have been reported, complete omission remains uncommon, and immunosuppressive strategies are not standardized across centers. Methods: We report 3 HLA-identical monozygotic twin pairs who underwent kidney transplantation without induction or maintenance immunosuppression. Allograft function was monitored longitudinally, with follow-up durations of 22, 10, and 4 y, respectively. All patients had immediate and sustained excellent graft function with no rejection episodes or native disease recurrence during follow-up. Results: Patient 1 was a 29-y-old man with chronic glomerulonephritis and had a largely uneventful course posttransplant. Patient 2 was a 61-y-old man who received his third graft from his monozygotic twin. Although highly sensitized because of previous transplants (calculated panel-reactive antibody = 62%), no desensitization or immunosuppressive therapy was administered, and graft function remained excellent without rejection. Patient 3 was a 43-y-old woman with IgA nephropathy, who was transplanted in high-risk cytomegalovirus constellation (donor [+]/recipient [-]). She developed a primary cytomegalovirus infection after cessation of 3-mo prophylaxis, which was successfully treated with valganciclovir. Conclusions: This case series demonstrates that kidney transplantation between HLA-identical monozygotic twins can achieve excellent long-term graft survival without any induction or maintenance immunosuppression.