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Abstract: PO2550

Granulomatous Interstitial Nephritis and Allograft Failure Secondary to Adenovirus Reactivation

Session Information

Category: Trainee Case Report

  • 1901 Transplantation: Basic

Authors

  • Khan, Mahnoor Mahmud, Mayo Clinic, Jacksonville, Florida, United States
  • Baker, Lyle Wesley, Mayo Clinic, Jacksonville, Florida, United States
  • Suliman, Sarah T., Mayo Clinic, Jacksonville, Florida, United States
  • Wadei, Hani, Mayo Clinic, Jacksonville, Florida, United States
Introduction

With an incidence of about 4% in renal transplant recipients, the typically self-limited adenovirus renders an infrequent propensity to cause allograft failure and life-threatening opportunistic infection in severe cases.

Case Description

A 29 year old female with history of living donor kidney transplant due to Henoch Schonlein Purpura (HSP) Glomerulonephritis with subsequent allograft failure underwent deceased donor re-transplantation with Anti-Thymocyte globulin induction. Post-op course was uneventful. Creatinine was 0.8 mg/dL on 4 month follow up. 6 months post-transplant, patient developed gross hematuria with clots, fever and acute kidney injury with creatinine of 2.82 mg/dL. Biopsy revealed granulomatous tubulointerstitial nephritis, extensive intra-nuclear viral inclusions with positive adenovirus immunohistochemistry (IHC). Mycophenolate Mofetil was discontinued and creatinine improved to 1.1 mg/dL. 3 months later, she was admitted for renal failure with creatinine of 7.2 mg/dL. Adenovirus was detected in the serum and urine. Repeat biopsy revealed markedly reactive tubular epithelium, widespread viral inclusions with negative adenovirus IHC, consistent with adenovirus nephropathy. Following a decrease in immunosuppression with improvement in renal function, adenovirus viral load became undetectable in both plasma and urine. The use of Cidofovir was considered for treatment; however, given risk of nephrotoxicity, was ultimately deferred after response to conservative treatment.

Discussion

Recurrence of HSP was in the broad differential given the initial presentation. Given its rarity, a paucity of cases and epidemiologic literature exists in illustrating allograft failure due to adenovirus nephropathy. Further research is not only needed to expand awareness of its presenting features and characteristic biopsy findings, but also, to limit more familiar culprits in masquerading as the elusive adenovirus infection, particularly in light of indeterminate therapeutic modalities.

A. Granulomatous interstitial nephritis; H&E
B. + Adenovirus Immunohistochemistry (Arrows)
C. Viral inclusions; EM