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Abstract: SA-PO879

Treatment Dilemma: De Novo Focal Segmental Glomerulosclerosis (FSGS) in the Setting of Kaposi Sarcoma in a Heart-Kidney Transplant Recipient

Session Information

Category: Transplantation

  • 2002 Transplantation: Clinical

Authors

  • Ruberwa, Joseph, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
  • Kotzen, Elizabeth, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
  • Kleman, Mark A., The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
Introduction

We present a case of de novo FSGS in the setting of cutaneous kaposi sarcoma in a combined heart-kidney transplant recipient six months after transplant.

Case Description

A 48-year-old male status post combined heart and kidney transplant for non-ischemic cardiomyopathy and cardiorenal syndrome respectively; he also has well controlled HIV. Induction immunosuppression was basiliximab and methylprednisolone, and maintenance immunosuppression was tacrolimus, mycophenolate mofetil and prednisone. Post-transplant creatinine was 2.1-2.5.

Six months post transplantation, he reported left leg hyper-pigmented macules and nodules that appeared gradually over the prior two months. Skin biopsy showed kaposi sarcoma with immunostain positive for human herpesvirus-8.
At the same period, the patient developed nephrotic range proteinuria with urine protein to creatinine ratio (UPCR) of 4.7 g/g. Kidney biopsy demonstrated mild FSGS, and electron microscopy (EM) demonstrated 20% foot process effacement.
Multiple UPCR prior to and in the first four months post-transplantation showed no proteinuria. Additionally, kidney biopsy done five weeks prior to this presentation for elevated creatinine had showed only focal interstitial fibrosis with normal glomerular basement membranes on EM.

For de novo FSGS, the patient received six sessions of plasmapheresis and valsartan started. The UPCR improved to 1.5 g/g.
Management of kaposi sarcoma was mainly modification of immunosuppression due to absence of visceral involvement. Mycophenolate mofetil was stopped, and later after proteinuria improved, sirolimus was initiated.

At the last follow-up, the patient had an increase in both creatinine and UPCR. We anticipate reporting longer-term follow-up at the time of the meeting.

Discussion

We are not aware of case reports of de novo FSGS in kidney transplant recipients being associated with Kaposi sarcoma. In this case it is difficult to know whether the Kaposi served as an inciting event but the timeline raises this possibility.
Sirolimus has become a cornerstone of management of Kaposi sarcoma in solid organ transplant recipients because of its antitumor effects (1,2). However, sirolimus is associated with proteinuria and FSGS (3,4,5). We therefore experienced a treatment dilemma between the potential benefit and risk of sirolimus.