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LIFE-THREATENING NECROTIZING MUCORMYCOSIS PNEUMONIA IN A HIGHLY SENSITIZED KIDNEY TRANSPLANT RECIPIENT: BALANCE BETWEEN INFECTIOUS RISK AND SUCCESSFUL TRANSPLANTATION
NKF 2015 Spring Clinical Meetings Abstracts
277 DISSEMINATED ADENOVIRAL GRANULOMATOUS INTERSTITIAL NEPHRITIS IN A SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANT RECIPIENT 1Ekamol Tantisattamo, 2Venkatesh Kumar Ariyamuthu, 1Aneesha A. Shetty, 1 Michael G. Ison, 1Northwestern University, 2Loyola University, IL Although adenovirus generally causes self-limited infection, it can rarely lead to more severe infection in transplant recipients. A 39-year-old man with ESRD underwent an uneventful simultaneous pancreas-kidney transplantation with alemtuzumab induction. Maintenance immunosuppressive medications included tacrolimus (FK) and mycophenolic acid (MPA). Two months later, he presented with fever, diarrhea, new onset hematuria (urinalysis showed 11-50 RBC/hpf) and acute kidney injury (AKI) with an elevated serum creatinine (SCr) of 1.3 mg/dL from the baseline of 0.9 mg/dL. Transplant renal ultrasound revealed mild pelviectasis. Serum glucose, amylase, and lipase were slightly elevated. After intravenous fluid hydration, SCr still continued rising. An allograft biopsy revealed granulomatous inflammation. Immunohistochemical stain (ICS) was positive for adenovirus in several tubular nuclei and negative for SV40, bacteria, acid fast bacilli, or fungus. Given concern for adenovirus interstial nephritis, plasma and urine adenovirus PCRs were sent and were positive (ViraCor-IBT, Lee’s Summit, MO). MPA was held and FK was decreased to maintain a 12-hour trough level of 4-6 ng/mL. Follow-up plasma and urine adenovirus 3 weeks later were undetectable and renal function returning to the baseline. Adenovirus typically causes self-limited respiratory, gastrointestinal, or conjunctival diseases in normal hosts and a hemorrhagic nephritis/cystitis in immunosuppressed patients. It can cause granulomatous interstitial nephritis in kidney transplant recipients. Hallmarks include fever, hematuria and renal dysfunction in kidney transplant recipients. Biopsy of the allograft often shows interstial nephritis with or without granulomas and always is positive for adenovirus by ICS; urinary PCR is universally positive. Cases can typically be managed with reduction of immunosuppression which typically results in clearance of infection over the subsequent weeks. With the appropriate clinical presentation, adenovirus nephritis should be considered and tested for.
278 KINETIC GLOMERULAR FILTRATION RATE: CLINICAL UTILITY IN MANAGING ACUTE KIDNEY INJURY Ekamol Tantisattamo, Northwestern University, Chicago, IL, USA Estimated glomerular filtration (eGFR) is insensitive and unreliable marker for estimating renal function especially in the setting of acute kidney injury (AKI). Kinetic glomerular filtration rate (KeGFR) is more accurate in assess renal function. A 60-year-old African American man with ESLD status post liver transplantation 2.5 years ago underwent cystoscopy and bladder biopsies for abnormal urine cytology. On post-procedure day (PPD)1, he developed oliguric AKI with elevated serum creatinine (SCr) of 4.05 mg/dl from the baseline SCr of 1.95 mg/dl with an eGFR (MDRD) was 45 ml/min/1.73m2. Urine output (UOP) was 200 ml/24 hours. However, by using KeGFR formula, eGFR was almost 0 ml/min. He was then anuric and SCr had been rising up to the peak of 17 mg/dl on PPD5 and hemodialysis catheter was placed. However, eGFR by KeGFR already showed improving renal function. On the next day, he had polyuria with UOP of 10 L over 24 hours and SCr decreased to 15.46 mg/dL. eGFR by KeGFR continued increasing. eGFR from MDRD over- and under-estimated renal function at the initial and recovery phase of AKI, respectively. On PPD8, SCr decreased to 2.7 mg/dL. He did not need dialysis and hemodialysis catheter was removed. In AKI, SCr is not a poor marker to assess renal function and eGFR by MDRD could not be applied. Increased UOP is one of the most important evidences of renal recovery in oliguric AKI; however, this is not always the case as demonstrated in our patient whose renal function estimating from KeGFR started to improve even during anuria on PPD5. Restrospectively, hemodialysis catheter was placed on that day when SCr was peak; however, improving renal function by using KeGFR formula can assist us to estimate eGFR confidently and hemodialysis catheter placement could be avoided. KeGFR is an existing formula to estimate GFR especially in oliguric AKI but not widely used. Only daily SCr, which is routinely checked, is required to calculate eGFR from KeGFR formula which allows us to apply this simple calculation at bedside for better estimating renal function and care of the patients.
A84
279 LIFE-THREATENING NECROTIZING MUCORMYCOSIS PNEUMONIA IN A HIGHLY SENSITIZED KIDNEY TRANSPLANT RECIPIENT: BALANCE BETWEEN INFECTIOUS RISK AND SUCCESSFUL TRANSPLANTATION Ekamol Tantisattamo, Division of Nephrology and Hypertension, Northwestern University, Chicago, IL, USA Opportunistic infection is one of the most common causes of morbidity and mortality in kidney transplant recipients. The state of immunosuppression results in potential life-threatening conditions. A 44-year-old man with ESRD due to hypertension underwent the first kidney transplantation 16 years ago. One year later, he developed new onset diabetes and the renal allograft failed 13 years posttransplantation due to calcineurin inhibitor nephrotoxicity. He had then been on hemodialysis for 4 years and underwent a deceased donor renal transplantation with preoperative rituximab infusion given a high sensitization. Maintenance immunosuppressive medications include tacrolimus, mycophenolate mofetil (MMF), and prednisone. Six weeks after the second kidney transplantation, he presented with cough for 1 week. CBC revealed WBC of 55,000 /μL. HbA1c was >13.9%. Chest x-ray showed a 13 cm lesion in the right lung. Chest CT scan revealed a large abscess of the right middle and lower lobe. He developed respiratory failure requiring intubation. Right middle and lower lobectomy was performed and pathology revealed acute bronchopneumonia with numerous fungal organisms consistent with mucor. Amphotericin B and micarfunfin were started. Tacrolimus and MMF were discontinued. After 14 days of hospitalization, he had PEA arrest and expired. Mucormycosis is ubiquitous but can lead to a life-threatening infection in immunocompromized host. Our patient had multiple risks factor of mucormycosis including uncontrolled diabetes in the setting of recent kidney transplantation with pretransplant rituximab for high sensitization. Our case illustrates that sensitization is still a major barrier to successful transplantation. Even though pretransplantation with antiCD20 may result in promising in lower chance of antibody medicated rejection, this strategy should be individualized and recipients should be carefully selected especially in such a high infectious risk patient.
280 Heavy Proteinuria > 50 Grams- Is it DIABETES OR SOMETHING ELSE: Thakur Hameer, Parikshit MD. Chaudhari, Nikulkumar MD, Naheed, Ansari MD. Jacobi Medical Center , Albert Einstein College of Medicine , Bronx ,NY , USA Diabetic nephrpathy is associated with variable amount of proteinuria including nephrotic syndrome. Massive proteinuria > 20 grams is very uncommon due to diabetic nephropathy. A 53 year old male with PMH of HTN, HLD, DM on insulin pump and Peripheral vascular disease with lower extremity digit amputations , diabetic retinopathy, CKD stage 3 was admitted to CCU with Hypertensive Emergency (BP 227/108 mm Hg ), worsening renal function ( Baseline serum creatinine 2.2 mg/dl to admission value of 4.5mg/dl), severe hyperlipidemia (both Hypertriglyceridemia and Hypercholesterolemia) . Patient was started on parentral antihypertensive agent for blood pressure control. Aggressive BP control led to few hypotensive episodes lasting for few hours ( BP 93/53 mm Hg ) on parentral therapy which resulted in further deteriorating of renal function . Serum Creatinine peaked to 14.1 mg/dl after hypotensive episode with muddy brown casts on urine sediment. Work up of AKI on CKD revealed urine Protein creatinine ratio of 53 grams, normal serum albumin (4gm/dl) and LDL of 307. Diagnosis of AKI on CKD due to ATN as a result of aggressive BP control was made and parentral anti-hypertensive medications were adjusted to keep systolic blood pressure around 150-160mm.Hg. Serological work up for heavy proteinuria was inconclusive. USG Abdomen was consistent with renal parenchymal disease. Doppler ultrasound of Renal arteries was negative for any arterial stenosis . Patient was started on Hemodialysis due to severe azotemia and volume overload . Patient underwent diagnostic renal biopsy which revealed . Nodular diabetic glomerulosclerosis, advanced. Tubular atrophy and interstitial fibrosis, severe (85%), with focal acute tubular injury. Arterio and arteriolosclerosis and hyalinosis, moderate to severe. The patient was on Hemodialysis for 2 weeks after which he recovered his renal function to new baseline serum creatinine of 4 mg/dl. We conclude that Diabetic Nephropathy can present with > 50 grams of proteinuria with normal serum albumin as in this biopsy proven case of Diabetic Nephropathy .
Am J Kidney Dis. 2015;65(4):A1-A93
277 DISSEMINATED ADENOVIRAL GRANULOMATOUS INTERSTITIAL NEPHRITIS IN A SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANT RECIPIENT 1Ekamol Tantisattamo, 2Venkatesh Kumar Ariyamuthu, 1Aneesha A. Shetty, 1 Michael G. Ison, 1Northwestern University, 2Loyola University, IL Although adenovirus generally causes self-limited infection, it can rarely lead to more severe infection in transplant recipients. A 39-year-old man with ESRD underwent an uneventful simultaneous pancreas-kidney transplantation with alemtuzumab induction. Maintenance immunosuppressive medications included tacrolimus (FK) and mycophenolic acid (MPA). Two months later, he presented with fever, diarrhea, new onset hematuria (urinalysis showed 11-50 RBC/hpf) and acute kidney injury (AKI) with an elevated serum creatinine (SCr) of 1.3 mg/dL from the baseline of 0.9 mg/dL. Transplant renal ultrasound revealed mild pelviectasis. Serum glucose, amylase, and lipase were slightly elevated. After intravenous fluid hydration, SCr still continued rising. An allograft biopsy revealed granulomatous inflammation. Immunohistochemical stain (ICS) was positive for adenovirus in several tubular nuclei and negative for SV40, bacteria, acid fast bacilli, or fungus. Given concern for adenovirus interstial nephritis, plasma and urine adenovirus PCRs were sent and were positive (ViraCor-IBT, Lee’s Summit, MO). MPA was held and FK was decreased to maintain a 12-hour trough level of 4-6 ng/mL. Follow-up plasma and urine adenovirus 3 weeks later were undetectable and renal function returning to the baseline. Adenovirus typically causes self-limited respiratory, gastrointestinal, or conjunctival diseases in normal hosts and a hemorrhagic nephritis/cystitis in immunosuppressed patients. It can cause granulomatous interstitial nephritis in kidney transplant recipients. Hallmarks include fever, hematuria and renal dysfunction in kidney transplant recipients. Biopsy of the allograft often shows interstial nephritis with or without granulomas and always is positive for adenovirus by ICS; urinary PCR is universally positive. Cases can typically be managed with reduction of immunosuppression which typically results in clearance of infection over the subsequent weeks. With the appropriate clinical presentation, adenovirus nephritis should be considered and tested for.
278 KINETIC GLOMERULAR FILTRATION RATE: CLINICAL UTILITY IN MANAGING ACUTE KIDNEY INJURY Ekamol Tantisattamo, Northwestern University, Chicago, IL, USA Estimated glomerular filtration (eGFR) is insensitive and unreliable marker for estimating renal function especially in the setting of acute kidney injury (AKI). Kinetic glomerular filtration rate (KeGFR) is more accurate in assess renal function. A 60-year-old African American man with ESLD status post liver transplantation 2.5 years ago underwent cystoscopy and bladder biopsies for abnormal urine cytology. On post-procedure day (PPD)1, he developed oliguric AKI with elevated serum creatinine (SCr) of 4.05 mg/dl from the baseline SCr of 1.95 mg/dl with an eGFR (MDRD) was 45 ml/min/1.73m2. Urine output (UOP) was 200 ml/24 hours. However, by using KeGFR formula, eGFR was almost 0 ml/min. He was then anuric and SCr had been rising up to the peak of 17 mg/dl on PPD5 and hemodialysis catheter was placed. However, eGFR by KeGFR already showed improving renal function. On the next day, he had polyuria with UOP of 10 L over 24 hours and SCr decreased to 15.46 mg/dL. eGFR by KeGFR continued increasing. eGFR from MDRD over- and under-estimated renal function at the initial and recovery phase of AKI, respectively. On PPD8, SCr decreased to 2.7 mg/dL. He did not need dialysis and hemodialysis catheter was removed. In AKI, SCr is not a poor marker to assess renal function and eGFR by MDRD could not be applied. Increased UOP is one of the most important evidences of renal recovery in oliguric AKI; however, this is not always the case as demonstrated in our patient whose renal function estimating from KeGFR started to improve even during anuria on PPD5. Restrospectively, hemodialysis catheter was placed on that day when SCr was peak; however, improving renal function by using KeGFR formula can assist us to estimate eGFR confidently and hemodialysis catheter placement could be avoided. KeGFR is an existing formula to estimate GFR especially in oliguric AKI but not widely used. Only daily SCr, which is routinely checked, is required to calculate eGFR from KeGFR formula which allows us to apply this simple calculation at bedside for better estimating renal function and care of the patients.
A84
279 LIFE-THREATENING NECROTIZING MUCORMYCOSIS PNEUMONIA IN A HIGHLY SENSITIZED KIDNEY TRANSPLANT RECIPIENT: BALANCE BETWEEN INFECTIOUS RISK AND SUCCESSFUL TRANSPLANTATION Ekamol Tantisattamo, Division of Nephrology and Hypertension, Northwestern University, Chicago, IL, USA Opportunistic infection is one of the most common causes of morbidity and mortality in kidney transplant recipients. The state of immunosuppression results in potential life-threatening conditions. A 44-year-old man with ESRD due to hypertension underwent the first kidney transplantation 16 years ago. One year later, he developed new onset diabetes and the renal allograft failed 13 years posttransplantation due to calcineurin inhibitor nephrotoxicity. He had then been on hemodialysis for 4 years and underwent a deceased donor renal transplantation with preoperative rituximab infusion given a high sensitization. Maintenance immunosuppressive medications include tacrolimus, mycophenolate mofetil (MMF), and prednisone. Six weeks after the second kidney transplantation, he presented with cough for 1 week. CBC revealed WBC of 55,000 /μL. HbA1c was >13.9%. Chest x-ray showed a 13 cm lesion in the right lung. Chest CT scan revealed a large abscess of the right middle and lower lobe. He developed respiratory failure requiring intubation. Right middle and lower lobectomy was performed and pathology revealed acute bronchopneumonia with numerous fungal organisms consistent with mucor. Amphotericin B and micarfunfin were started. Tacrolimus and MMF were discontinued. After 14 days of hospitalization, he had PEA arrest and expired. Mucormycosis is ubiquitous but can lead to a life-threatening infection in immunocompromized host. Our patient had multiple risks factor of mucormycosis including uncontrolled diabetes in the setting of recent kidney transplantation with pretransplant rituximab for high sensitization. Our case illustrates that sensitization is still a major barrier to successful transplantation. Even though pretransplantation with antiCD20 may result in promising in lower chance of antibody medicated rejection, this strategy should be individualized and recipients should be carefully selected especially in such a high infectious risk patient.
280 Heavy Proteinuria > 50 Grams- Is it DIABETES OR SOMETHING ELSE: Thakur Hameer, Parikshit MD. Chaudhari, Nikulkumar MD, Naheed, Ansari MD. Jacobi Medical Center , Albert Einstein College of Medicine , Bronx ,NY , USA Diabetic nephrpathy is associated with variable amount of proteinuria including nephrotic syndrome. Massive proteinuria > 20 grams is very uncommon due to diabetic nephropathy. A 53 year old male with PMH of HTN, HLD, DM on insulin pump and Peripheral vascular disease with lower extremity digit amputations , diabetic retinopathy, CKD stage 3 was admitted to CCU with Hypertensive Emergency (BP 227/108 mm Hg ), worsening renal function ( Baseline serum creatinine 2.2 mg/dl to admission value of 4.5mg/dl), severe hyperlipidemia (both Hypertriglyceridemia and Hypercholesterolemia) . Patient was started on parentral antihypertensive agent for blood pressure control. Aggressive BP control led to few hypotensive episodes lasting for few hours ( BP 93/53 mm Hg ) on parentral therapy which resulted in further deteriorating of renal function . Serum Creatinine peaked to 14.1 mg/dl after hypotensive episode with muddy brown casts on urine sediment. Work up of AKI on CKD revealed urine Protein creatinine ratio of 53 grams, normal serum albumin (4gm/dl) and LDL of 307. Diagnosis of AKI on CKD due to ATN as a result of aggressive BP control was made and parentral anti-hypertensive medications were adjusted to keep systolic blood pressure around 150-160mm.Hg. Serological work up for heavy proteinuria was inconclusive. USG Abdomen was consistent with renal parenchymal disease. Doppler ultrasound of Renal arteries was negative for any arterial stenosis . Patient was started on Hemodialysis due to severe azotemia and volume overload . Patient underwent diagnostic renal biopsy which revealed . Nodular diabetic glomerulosclerosis, advanced. Tubular atrophy and interstitial fibrosis, severe (85%), with focal acute tubular injury. Arterio and arteriolosclerosis and hyalinosis, moderate to severe. The patient was on Hemodialysis for 2 weeks after which he recovered his renal function to new baseline serum creatinine of 4 mg/dl. We conclude that Diabetic Nephropathy can present with > 50 grams of proteinuria with normal serum albumin as in this biopsy proven case of Diabetic Nephropathy .
Am J Kidney Dis. 2015;65(4):A1-A93