Abstract: TH-PO593
Blood in a Urine Collection...Is It an Infection or Rejection? Adenovirus Is Our Selection!
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
- AbdulRahim, Nashila, UTSouthwestern, Dallas, Texas, United States
- Ellington, Natalie Elise, UTSouthwestern, Dallas, Texas, United States
- Hendricks, Allen, UTSouthwestern, Dallas, Texas, United States
- Tanriover, Bekir, UTSouthwestern, Dallas, Texas, United States
- Ariyamuthu, Venkatesh Kumar, UTSouthwestern, Dallas, Texas, United States
Introduction
Adenovirus-induced granulomatous interstitial nephritis (AGIN) is rare and has a high risk of graft loss in renal transplant patients. Diagnosis can be made with quantitative urine and blood PCRs and biopsy. We present a case of hemorrhagic cystitis, AGIN, admixed with rejection.
Case Description
53 year old male with a history of ESRD secondary to ADPKD had a DDRT in 2010 with no notable post-transplant complications. His baseline SCr was 1.6 mg/dl, and he was maintained on tacrolimus, MPA, and prednisone, with goal tacrolimus troughs between 5-8 ng/ml.
He had presented to an urgent care with dysuria, hematuria, and AKI (Scr to 1.9 mg/dl) and treated with ciprofloxacin for 10 days. He came to our facility one week later with diarrhea, fevers, and AKI (SCr of 2.9 mg/dl) that did not improve with IV fluids and antibiotics. In light of hematuria, urine and serum adenovirus PCR were sent which resulted as greater than 2,000,000 and 72,698 copies respectively. Transplant kidney biopsy showed ACR Banff IB, suspicious for chronic, active ABMR with severe glomerulitis, moderate pertitubular capillaritis, and mild transplant glomerulopathy. Light microscopy showed severe tubulointerstitial inflammation with lymphohistiocytic proliferation, numerous monocytes and lymphocytes with areas of interstitial hemorrhage, epithelial cell necrosis, rupture of basement membranes, and rare tubular epithelial cells with enlarged nuclei with a smudgy, glassy appearance. Occasional vague necrotizing granulomas were identified. Electron microscopy showed 30-40% foot process effacement with segmental duplication of capillary walls.
SCr peaked at 3.2 mg/dl; he received IVIG for AGIN. Dose of prednisone was increased to 10 mg, and tacrolimus level ran between 5-8 ng/ml with MPA at 360 mg bid. He was unable to tolerate further IVIG secondary to headaches. Serum adenovirus PCR one week after IVIG dosing had detectable viral loads but less than 500 copies. Discussion with Transplant ID colleagues led to the decision to hold cidofovir secondary to potential nephrotoxicity. His renal function remains stable at SCr of 1.8 mg/dl.
Discussion
We identified and properly treated a rare cause of AKI due to AGIN admixed with ACR. Prompt diagnosis and treatment led to resolution of viremia as well as improvement in renal function with graft salvage.