Abstract: SA-PO952
Hidden, Donor-Derived Malignancy: A Tale of Two Kidneys
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
- Pamarthy, Amaleswari, UMMC, Madison, Mississippi, United States
- Vaitla, Pradeep, None, Madison, Mississippi, United States
Background
PTLD (Post-transplant lymphoproliferative disorder) is a relatively common malignancy but rarely donor derived. PTLD includes clinical syndromes ranging from uncomplicated post-transplant infectious mononucleosis to true malignancies that contain clonal chromosomal abnormalities which may or may not be associated with EBV infection. Most cases occur in the first year. Mortality is as high 50-80% in monoclonal form. High index of suspicion and clinical vigilance is critical since patients can present with nonspecific symptoms & signs. Pathophysiology is not well understood. Hence anticipation and prevention of PTLD remains a challenge.
Methods
Mate kidneys obtained from EBV and CMV IgG negative donor were transplanted to 69-year-old male and 68-year-old female who were positive for EBV IgG and CMV IgG. Kidney and spleen biopsies were done at procurement. Both patients received induction with Anti-thymocyte globulin and maintained on Tacrolimus, Mycophenolate mofetil, Prednisone. Kidney biopsies at the time of transplant did not show any evidence of disease process. Post-transplantation, pathology of donor's spleen revealed plasmacytoma. Hence both recipients called in for further work. SPEP was unremarkable, serum free light chains showed a mild increase in lambda light chains, which were followed regularly. One patient developed abdominal pain 4 months post transplant and imaging revealed 10cm mass arising from transplant kidney, the biopsy confirmed plasmacytoma. The second patient presented with urinary retention and imaging revealed a large para-aortic lymph nodal mass. Biopsy confirmed plasmacytoma as well. Both patients were started on chemotherapy and doing fairly well now.
Conclusion
Despite having a normal kidney biopsy at the time of transplant, donor-derived malignancy can be transmitted through lymphatics of the donor organs. If suspicion for PTLD is high, more aggressive screening and high clinical vigilance is indicated. Negative bonemarrow biopsies might not preclude from having PTLD. If high suspicion for EBV-related PTLD present, prophylactic therapies, including antiviral agents and immunoglobulins were proposed but need to be tested in randomized, placebo-controlled trials to determine their true efficacy. Decreasing the immunosuppression is the cornerstone and might help with regression of the PTLD, sometimes aggressive chemotherapy is indicated as presented above.