Abstract: TH-PO579
Secondary Focal Segmental Glomerulosclerosis in Pregnancy: A Risk for Renal Transplant Patients
Session Information
- Trainee Case Reports - II
October 25, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1802 Transplantation: Clinical
Authors
- Dines, Virginia, Mayo Clinic , Rochester, Minnesota, United States
- D'Costa, Matthew R., Mayo Clinic , Rochester , Minnesota, United States
- Kattah, Andrea G., Mayo Clinic , Rochester , Minnesota, United States
Introduction
Pre/eclampsia is usually the cause of worsening hypertension and proteinuria in pregnancy; however, these findings in a renal transplant patient lead to a wider differential. We present a case of focal segmental glomerulosclerosis (FSGS) in a pregnant patient 16 years post renal transplant.
Case Description
A 39 year old female with end stage renal disease secondary to lupus nephritis status/post living related kidney transplant, obesity, and hypertension presented with marked proteinuria and worsening hypertension at 14 weeks gestation. Her post-transplant course had been uncomplicated by proteinuria. At presentation, she developed worsening hypertension and 24h total protein was 3.2 g. With strict blood pressure control, urine albumin-to-creatinine ratio (ACR) decreased to 641 mg/g (figure). At 20 weeks, ACR increased to 4399 in the setting of worsening hypertension. She was admitted to the hospital, and urinalysis showed no hematuria and C3/C4, dsDNA and other serologic workup was negative. Kidney biopsy revealed cellular FSGS with glomerulomegaly and 70% foot process effacement, concerning for hyperfiltration injury vs de novo primary FSGS. Proteinuria initially improved with strict blood pressure control; however she developed worsening hypertension, proteinuria, and edema at 36 weeks gestation due to pre-eclampsia and underwent cesarean section. She continued to have nephrotic range proteinuria, and renal biopsy at 11 weeks post-partum demonstrated features of secondary FSGS.
Discussion
The differential for proteinuria and hypertension in pregnant renal transplant patients includes pre/eclampsia, rejection, transplant glomerulopathy, and recurrent or de novo glomerular disease. Pregnancy creates a physiologic state of hyperfiltration due to increased fluid retention and blood flow. While allografts generally adapt to these changes, patients with obesity and uncontrolled hypertension are at risk for hyperfiltration-induced renal injury and FSGS, which in this case, was unmasked by pregnancy.