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Kidney Week

Abstract: FR-PO787

Progressive Dysphagia in Kidney Transplant Recipient: An Unusual Cause

Session Information

Category: Transplantation

  • 2102 Transplantation: Clinical

Authors

  • Ryhal, Robert, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
  • Daloul, Reem, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
  • Nashar, Khaled, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
  • Sureshkumar, Kalathil K., Allegheny Health Network, Pittsburgh, Pennsylvania, United States
Introduction

Upper gastrointestinal (GI) symptoms such as dysphagia and odynophagia in immunocompromised hosts are generally caused by viral or fungal infections. We present a kidney transplant recipient who developed progressive dysphagia and odynophagia caused by mycophenolate mofetil (MMF) that improved after discontinuation of MMF and serial endoscopic esophageal dilatation.

Case Description

A 49-year old male (CMV IgG-,EBV IgG+) received kidney transplantation from sister (CMV IgG+, EBV IgG+) with Thymoglobulin induction, tacrolimus/MMF maintenance and infection prophylaxis using valgancyclovir, trimethoprim-sulfamethoxazole and nystain. There was immediate allograft function with discharge serum creatinine of 1.5 mg/dl. One month later, patient presented with progressive dysphagia and odynophagia with reduced appetite and weight loss.MMF was discontinued and replaced with azathioprine. Upper endoscopy showed benign appearing intrinsic severe distal esophageal stenosis (Figure 1A). The stricture was dilated to 7 mm and biopsy showed focal acute inflammation (Figure 1B). PAS staining for fungal elements and immunohistochemistry for CMV and HSV type1/2 were negative. Patient required 9 more stricture dilatations over the next 3 months to a final diameter of 18 mm. His dysphagia gradually resolved with improvement in dietary intake and weight gain over next few months.

Discussion

MMF has several GI side effects and more commonly involve lower GI tract. MMF-related esophageal stricture is extremely rare. The mechanism is not clear but may involve MMF-induced blockade of guanosine nucleotide synthesis thus disrupting GI epithelial barrier. MMF-metabolites may also cause autoimmunity and hypersensitivity-like reactions. Our case highlights MMF as an uncommon cause of esophageal stricture and should be considered as a potential etiology of dysphagia in a transplant recipient.

Figure 1: (A) Upper endoscopy showing benign appearing intrinsic severe distal esophageal stenosis that was 5 cm long and 4 mm in diameter. (B) H&E staining of stricture area biopsy showing benign squamous mucosa with reactive changes and focal acute inflammation.