Abstract: SA-PO945

Disseminated Adenoviral Infection with Nephropathy in a Kidney/Pancreas Transplant Recipient

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Nesmith, Natalie, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Kapp, Meghan E., Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Fogo, Agnes B., Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Paueksakon, Paisit, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Satyanarayana, Gowri, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Schaefer, Heidi M., Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Helderman, J.H., Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Concepcion, Beatrice P., Vanderbilt University Medical Center, Nashville, Tennessee, United States
Background

Adenovirus (AV) is a commonly encountered viral pathogen with self-limited infection in immunocompetent hosts. In immunocompromised hosts more serious complications can occur. We report a kidney/pancreas (KP) transplant recipient who developed disseminated adenoviral infection with nephropathy which was successfully treated with cidofovir.

Methods

A 32 year old man with Type I Diabetes Mellitus with diabetic nephropathy, retinopathy, and peripheral vascular disease underwent simultaneous KP transplant in 10/2016. He was induced with solumedrol and alemtuzumab. Maintenance therapy included three drug regimen with tacrolimus, prednisone and mycophenolate mofetil. Two months later he developed gross hematuria, high-grade fevers, and acute kidney injury (sCr 1.46 mg/dL vs baseline sCr 0.8 mg/dL). Amylase/lipase were normal. Serum (>2million copies/mL) and urine AV PCR were positive with positive AV nasal swab . He underwent transplant biopsy which showed multifocal tubulocentric necrotizing granulomas with viral cytopathic nuclear changes in tubular epithelial cells and podocytes, the latter associated with a cellular crescent with fibrinoid necrosis and apoptotic debris. Electron microscopy demonstrated focal crystalline viral particles in tubules. Immunohistochemical stains were diffusely positive for AV and negative for SV40. There was no evidence of concomitant acute cellular rejection and no diagnostic evidence of antibody-mediated rejection with negative C4d by immunofluorescence. He was started on cidofovir/probenecid with resolution of fevers after two doses and ultimately received eight doses. Four months later, serum AV PCR was negative and sCr was 1.5 mg/dL.

Conclusion

While disseminated adenovirus is rare amongst KP transplant recipients, it can cause serious complications including multi-organ dysfunction, graft loss, and death. Severe disease including AV nephropathy warrants treatment with cidofovir despite its nephrotoxicity.