Abstract: SA-PO1135
Simultaneous Acute Rejection and Recurrent Focal Segmental Glomerulosclerosis: A Match Made in Renal Transplantation
Session Information
- Transplant Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 1902 Transplantation: Clinical
Authors
- Shah, Anita, Baylor College of Medicine, Houston, Texas, United States
- Shah, Maulin, Baylor College of Medicine, Houston, Texas, United States
- Ramanathan, Venkat, Baylor College of Medicine, Houston, Texas, United States
Introduction
Simultaneous recurrent focal segmental glomerulosclerosis (FSGS) and acute rejection is extremely rare in kidney transplant recipients. In resistant FSGS cases failing conventional immunosuppression, addition of repository corticotropin injection (Acthar Gel®) may lead to proteinuria resolution.
Case Description
A 34-year-old man underwent deceased donor kidney transplantation for ESRD related to possible FSGS. Other medical history included hypertension and obesity. He had immediate allograft function with basiliximab induction. Maintenance regimen included tacrolimus, mycophenolate and prednisone. Eleven weeks after transplantation, he had sudden onset of nephrotic-range proteinuria (urine protein-creatinine ratio of 11.3 g/g from baseline of 0.5 g/g), generalized edema and acute kidney injury (serum creatinine 2.4 mg/dL from baseline 1.6 mg/dL). Kidney transplant biopsy was performed expecting histologic evidence of recurrent FSGS. Surprisingly, biopsy showed Banff II-B acute cellular rejection and segmental podocyte injury. He was treated for rejection and recurrent FSGS with anti-thymocyte globulin, solumedrol, plasmapheresis (TPE) and IVIg. Following TPE and immunosuppression intensification, his proteinuria improved briskly to 0.37 g/g with parallel decline in creatinine to baseline. Despite ongoing TPE and IVIg, his proteinuria recurred (8-10 g/g) with worsening creatinine. Repeat kidney biopsy showed complete resolution of rejection, but with 25% residual foot process effacement. With failure of two doses of rituximab and 40 TPE sessions to improve his proteinuria, he started corticotropin injections twice weekly. After 3 months of corticotropin, TPE was stopped, and corticotropin tapered off over another 3 months. He is now in complete remission of proteinuria with stable kidney function.
Discussion
Pre-transplant FSGS patients should be closely monitored in the post-transplant period for FSGS recurrence. Simultaneous presence of two diagnoses underscores the importance of performing kidney biopsy in those with proteinuria and acute kidney injury post-transplantation. Recurrent FSGS treatment in allografts resistant to conventional treatments may remit with corticotropin. Concurrent acute vascular rejection and recurrent FSGS is rare. In the era of significant organ shortage, all options should be tried to save the allograft.