Abstract: TH-PO598
CMV Nephritis with Glomerular Involvement
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
Author
- Alsawah, Mohammad Y., St John Hospital & Medical Center, Detorit, Michigan, United States
Introduction
Cytomegalovirus (CMV) infection is common in kidney transplant recipients, but infection related pathologic changes of the renal allograft are uncommon. Histologically, it presents with viral inclusions in tubular epithelial cells and interstitial inflammation. We describe a case of CMV nephritis with inclusions in glomerular endothelial cells without associated interstitial infiltrate or epithelial cell inclusions.
Case Description
A 17 year old African American male with history of ESRD from focal segmental glomerulosclerosis received a preemptive living kidney allograft from his mother. Both donor and recipient were CMV seropositive. Post-operatively, creatinine level plateaued at 2 mg/dL without significant proteinuria on serial monitoring. An allograft biopsy was performed for elevated creatinine level 5 weeks post-transplant showed no evidence of rejection or recurrence of the primary disease. Staining for both SV40 and CMV was negative.
Three months postoperatively, the patient developed abdominal pain and weight loss. Abdominal CT scan showed no abnormalities. Gastric endoscopy showed mild gastritis. A peripheral blood quantitative CMV viral load by PCR was >3 million copies / ml. The patient’s creatinine level increased to 2.5 mg/dL. A repeat allograft biopsy showed enlarged endothelial cells with cytoplasmic inclusion that stained positive for CMV. There was no evidence of capillary thrombosis, interstitial inflammation or tubular epithelial cell inclusions. Peripheral blood CMV viral load was elevated over 3 million IU/ml despite receiving maintenance valganciclovir post-transplant prophylaxis. CMV viral resistance pattern revealed a UL97 mutation. Viremia ultimately responded to increasing valganciclovir dose over a 5 months period of follow-up.
Discussion
CMV induced cell inclusions in kidney allograft recipients with CMV disease is uncommon and usually involves epithelial tubular cells. Bhadauria et al described CMV infection in 74 of 521 live donor kidney recipients (1). Only 4 cases developed histologically confirmed CMV allograft disease. In another review of 2900 kidney allograft indication biopsies only 4 cases of glomerular endothelial cells were described(2). Ganciclovir resistance occur in 2-4% of CMV infections (3), but there are no reports of association of this resistance with any specific pathologic findings on kidney biopsy.