Abstract: SA-PO958
Renal Allograft Malakoplakia: A Rare Cause of Allograft Failure
Session Information
- Fellows/Residents Case Reports: ESRD: HD, PD, Transplant
November 04, 2017 | Location: Hall H, Morial Convention Center
Abstract Time: 10:00 AM - 10:00 AM
Category: Nephrology Education
- 1302 Fellows and Residents Case Reports
Authors
- Vasanth, Payaswini, Emory Univeristy, Atlanta, Georgia, United States
- Kenny Thomas, Jeffy, Emory Univeristy, Atlanta, Georgia, United States
- Rogers, Thomas E., Emory University, Atlanta, Georgia, United States
- Graves, Sharon M., Emory Univeristy, Atlanta, Georgia, United States
Background
Malakoplakia is an unusual granulomatous inflammatory disorder associated with diminished bactericidal action of leukocytes. Cases of renal allograft malakoplakia are rare and are generally associated with a poor graft and patient survival. We present a case of renal allograft malakoplakia triggered by repeated UTIs in the setting of recent increase in immunosuppression.
Methods
50-year-old female with history of pediatric en bloc kidney transplant with baseline allograft function ranging between 2-2.5mg/dl on immunosuppression regimen of low dose Tacrolimus (trough between 3-5), low dose MMF due to history of UTIs and BK viremia and prednisone. Her post transplant was complicated by recurrent E.coli UTIs and mesangioproliferative-type glomerulopathy, with prominent staining for IgM and C3 which is a variant of focal segmental glomerulosclerosis (FSGS), and hence her immunosuppression was increased to high dose prednisone with prolonged taper. Soon after she developed E.coli UTI and acute kidney injury, her creatinine increased to 9.5mg/dl. She was treated with IV Antibiotic rocephin and transitioned to oral Levoquin for 3 weeks. Her creatinine trended down to 4.2mg/dl and a biopsy was performed that showed epithelioid histiocytes with basophilic inclusions called Michaelis-Gutmann bodies suggestive of malakoplakia with severe IFTA. Her creatinine remained at 4mg/dl and we maintained her on low immunosuppression in the setting of malakoplakia.
Conclusion
Renal parenchymal malakoplakia is a rare cause of renal allograft failure. Currently, malakoplakia is thought to be associated with infection, E.coli is the most common. Therefore, agents targeting Gram negative bacteria with high bioavailability in macrophages are most commonly chosen, such as quinolones and sulfamido groups. In malakoplakia, macrophage dysfunction and persistent antigens within cells cause progressive delivery of cytokines, resulting in renal inflammation and further injury. If the early interstitial injury is not controlled, renal injury continues to deteriorate and even progresses to interstitial fibrosis even when bacteria is removed and is associated with poor graft outcome, as demonstrated in this case.