ASN's Mission

To create a world without kidney diseases, the ASN Alliance for Kidney Health elevates care by educating and informing, driving breakthroughs and innovation, and advocating for policies that create transformative changes in kidney medicine throughout the world.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005

email@asn-online.org

202-640-4660

The Latest on Twitter

Kidney Week

Abstract: SA-PO864

Severe Hydronephrosis in Kidney Transplant due to Ureteral Malakoplakia and Resolution With Immunosuppression Reduction and Antibiotics

Session Information

Category: Transplantation

  • 2002 Transplantation: Clinical

Authors

  • Rustom, David S., The University of Tennessee Health Science Center, Memphis, Tennessee, United States
  • Amin, Sahar, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
  • Wall, Barry M., The University of Tennessee Health Science Center, Memphis, Tennessee, United States
  • Talwar, Manish, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
  • Balaraman, Vasanthi, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
  • Bhalla, Anshul, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
Introduction

Malakoplakia is chronic granulomatous inflammation that can demonstrate pseudotumor characteristics. It most often affects the genitourinary tract, but ureteral involvement resulting in urinary tract obstruction is rare. In this report, we present a case of extensive malakoplakia surrounding a renal transplant and ureter causing severe hydronephrosis and AKI.

Case Description

55-year-old male with ESRD due to hypertension received a cadaveric kidney transplant in Nov 2020 with postoperative course complicated by recurrent urinary tract infections with Escherichia coli. He responded well to courses of antibiotics. However, he developed AKI (creatinine 3.3 mg/dL from baseline 2.0 mg/dL), in Feb 2021 and CT abdomen/pelvis revealed severe hydronephrosis of the transplant kidney and a multifocal hyperdense collection involving the renal transplant and ureter extending into surrounding structures and subcutaneous tissue of the abdominal wall to the skin surface. Due to concern for possible renal abscess, he was treated with IV antibiotics, and nephrostomy tube was placed with subsequent stent. Repeat CT in Mar 2021 showed progression of disease extent. To avoid seeding a potential abscess with invasive biopsy, he underwent superficial left abdominal wall biopsy, which showed foamy epithelioid histiocytes (CD68 positive) with granular eosinophilic cytoplasm and intracytoplasmic Michaelis-Gutmann bodies (Von Kossa positive), consistent with malakoplakia. Long-term antibiotics were continued with ceftriaxone that was transitioned to cefdinir, trimethoprim/sulfamethoxazole, and levofloxacin. Immunosuppression was reduced by discontinuing mycophenolic acid, lowering goal tacrolimus trough level, and maintaining low dose prednisone. Serial CT imaging over several months showed marked improvement in malakoplakia and complete resolution of hydronephrosis and AKI (creatinine 1.4 mg/dL). Ureteral stent was removed with no further hydronephrosis on imaging. Transplant kidney biopsy in June 2021 was negative for acute rejection.

Discussion

Malakoplakia can rarely involve a transplant kidney and ureter leading to severe urinary tract obstruction. In this report, we describe a case with gradual but dramatic response to management by treating with long-term antibiotics and reducing immunosuppression.