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Kidney Week

Abstract: PO2223

Richter Transformation (RT): A Rare Complication in Renal Transplant

Session Information

  • Onco-Nephrology - 2
    October 22, 2020 | Location: On-Demand
    Abstract Time: 10:00 AM - 12:00 PM

Category: Trainee Case Report

  • 1500 Onco-Nephrology

Authors

  • Marvania, Nirali V., LifeBridge Health, Baltimore, Maryland, United States
  • Mavanur, Manju, LifeBridge Health, Baltimore, Maryland, United States
Introduction

RT is conversion of B-cell chronic lymphocytic leukemia (CLL) into diffuse large B-cell lymphoma (DLBCL). We present a rare case of RT in a renal allograft.

Case Description

A 68 year old male was admitted for a syncopal episode and acute renal failure. He had significant medical history of ESRD secondary to diabetes and hypertensive nephrosclerosis, deceased donor renal transplant in 2015 on Mycophenolate and Tacrolimus, CLL diagnosed in 2017 on Ibrutinib, Stage III CKD of allograft with baseline creatinine 1.5 mg/dl. Initial work up revealed orthostatic hypotension and AKI with creatinine of 3.3 mg/dl. Urinalysis and microscopy was negative for proteinuria, hematuria, pyuria, casts or crystals. Renal ultrasound showed the size of transplant kidney was 10.7 x 5.8 x 4.3 cm with normal renal cortex and no demonstrated mass, cyst or hydronephrosis. Administration of IV NS and holding antihypertensive medications to correct orthostasis failed to improve renal function with creatinine rising up to 4.02 mg/dl. Transplant renal biopsy was done. Pathology results revealed no evidence of allograft rejection but extensive infiltration of renal parenchyma with atypical lymphocytes with high Ki-67 expression suggesting transformation to DLBCL in a patient with a known history of CLL. Lymphocytes retained their positivity for CD5 and CD23 which supported diagnosis of RT rather than post-transplant lympho-proliferative disorder (PTLD). Patient was continued on Ibrutinib, Tacrolimus, Prednisone 5mg daily and started on weekly Rituximab infusion. Mycophenolate was discontinued. Patient's renal function returned to its baseline after 2 doses of Rituximab. He was planned to continue Rituximab infusion as an outpatient.

Discussion

Transplant patients have high risk of RT due risk factors including concomitant immunosuppression, Eptstein-Barr virus infection and some with genetic susceptibility. While PTLD is a well-recognized complication of patients with renal transplants, RT is not that common. Immunochemotherapy is usually the preferred treatment for older patients with RT while allogeneic bone marrow transplantation may be curative in younger patients. Discussion between transplant physician and oncologist should be held, taking into account the new molecular prognostic markers prior to renal transplant. This may help in risk stratification of patients for conversion of CLL to RT.