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Nonspecific Interstitial Pneumonia in a Kidney Transplant Patient
Diffuse Lung Disease SESSION TITLE: Diffuse Lung Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
Nonspecific Interstitial Pneumonia in a Kidney Transplant Patient Landon Casaus* Sapna Bhatia Ali Saeed Rodrigo Vazquez Guillamet Samuel Reynolds and Loren Ketai University of New Mexico, Department of Internal Medicine, Albuquerque, NM INTRODUCTION: Non-specific Interstitial Pneumonia (NSIP) is one type of idiopathic interstitial pneumonia and can be seen in association with HIV infection, connective tissue diseases, or the use of certain medications such as nitrofurantoin and methotrexate. The histopathology of NSIP is characterized by varied proportions of interstitial inflammation and fibrosis in a pattern that suggests temporal homogeneity. The mainstay of treatment for NSIP involves the use of glucocorticoids and immunosuppressive drugs. We herein describe a case of a 71 year old gentleman status post kidney transplant who developed NSIP despite of the use of chronic glucocorticoid and immunosuppressive therapies.
DIFFUSE LUNG DISEASE
CASE PRESENTATION: A 71 year old ex-smoker with a past medical history significant for 4-vessel CABG, HTN and diabetes mellitus underwent right cadaveric kidney transplant in October of 2014 for end stage renal disease. Post operatively, the patient was placed on immunosuppressive medications including mycophenolic mofetil 360 mg bid, prednisone 15 mg daily, and tacrolimus 0.5 mg bid. In July of 2016, the patient developed dyspnea on exertion and a new oxygen requirement of 2 LPM. CT chest without contrast showed bibasilar reticular opacities, ground glass, and traction bronchiectasis without evidence of honeycombing. An autoimmune workup and HIV testing were negative, and the patient denied any chemical, dust, or fume exposures. The patient then underwent transbronchial cryobiopsies of the lateral segment of the right lower lobe of the lung and pathology revealed NSIP. DISCUSSION: We herein describe an unusual case of NSIP that developed in a patient while on chronic immunosuppressive therapy for renal transplant. Upon review of the literature, interstitial lung abnormalities have been described in up to 24% of kidney transplant patients receiving traditional immunosuppressive therapies. Etiologies included infection such as Pneumocysitis jiroveci pneumonia and drug induced from mTOR inhibitors, azathioprine and cyclosporine. In a case series by Bertolini et al, 2/ 63 renal transplant patients developed NSIP while on everolimus and mycophenolate mofetil therapy. Follow up CAT scans 20 months after the initial CAT scan showed no change in NSIP in one patient and complete resolution of NSIP in the other patient without a change in immunosuppressive therapy or dosage. CONCLUSIONS: The significance of development of NSIP in a renal transplant patient on chronic immunosuppressive therapy is unclear and there are currently no treatment guidelines. When evaluating similar patients, it is always important to rule out other infection or drug-related etiologies. Reference #1: Bertolini L, et al. Subclinical interstitial lung abnormalities in stable renal allograft recipients in the era of modern immunosupression. Transplantation Proceedings. 2011;43:2617-2623. Reference #2: Ewert R, et al. Abnormalities of Pulmonary Diffusion Capacity in Long-term Survivors After Kidney Transplantation. Chest. 2002;122(2):639-644. DISCLOSURE: The following authors have nothing to disclose: Landon Casaus, Sapna Bhatia, Ali Saeed, Rodrigo Vazquez Guillamet, Samuel Reynolds, Loren Ketai No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.461
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
434A
[
152#4S CHEST OCTOBER 2017
]
Nonspecific Interstitial Pneumonia in a Kidney Transplant Patient Landon Casaus* Sapna Bhatia Ali Saeed Rodrigo Vazquez Guillamet Samuel Reynolds and Loren Ketai University of New Mexico, Department of Internal Medicine, Albuquerque, NM INTRODUCTION: Non-specific Interstitial Pneumonia (NSIP) is one type of idiopathic interstitial pneumonia and can be seen in association with HIV infection, connective tissue diseases, or the use of certain medications such as nitrofurantoin and methotrexate. The histopathology of NSIP is characterized by varied proportions of interstitial inflammation and fibrosis in a pattern that suggests temporal homogeneity. The mainstay of treatment for NSIP involves the use of glucocorticoids and immunosuppressive drugs. We herein describe a case of a 71 year old gentleman status post kidney transplant who developed NSIP despite of the use of chronic glucocorticoid and immunosuppressive therapies.
DIFFUSE LUNG DISEASE
CASE PRESENTATION: A 71 year old ex-smoker with a past medical history significant for 4-vessel CABG, HTN and diabetes mellitus underwent right cadaveric kidney transplant in October of 2014 for end stage renal disease. Post operatively, the patient was placed on immunosuppressive medications including mycophenolic mofetil 360 mg bid, prednisone 15 mg daily, and tacrolimus 0.5 mg bid. In July of 2016, the patient developed dyspnea on exertion and a new oxygen requirement of 2 LPM. CT chest without contrast showed bibasilar reticular opacities, ground glass, and traction bronchiectasis without evidence of honeycombing. An autoimmune workup and HIV testing were negative, and the patient denied any chemical, dust, or fume exposures. The patient then underwent transbronchial cryobiopsies of the lateral segment of the right lower lobe of the lung and pathology revealed NSIP. DISCUSSION: We herein describe an unusual case of NSIP that developed in a patient while on chronic immunosuppressive therapy for renal transplant. Upon review of the literature, interstitial lung abnormalities have been described in up to 24% of kidney transplant patients receiving traditional immunosuppressive therapies. Etiologies included infection such as Pneumocysitis jiroveci pneumonia and drug induced from mTOR inhibitors, azathioprine and cyclosporine. In a case series by Bertolini et al, 2/ 63 renal transplant patients developed NSIP while on everolimus and mycophenolate mofetil therapy. Follow up CAT scans 20 months after the initial CAT scan showed no change in NSIP in one patient and complete resolution of NSIP in the other patient without a change in immunosuppressive therapy or dosage. CONCLUSIONS: The significance of development of NSIP in a renal transplant patient on chronic immunosuppressive therapy is unclear and there are currently no treatment guidelines. When evaluating similar patients, it is always important to rule out other infection or drug-related etiologies. Reference #1: Bertolini L, et al. Subclinical interstitial lung abnormalities in stable renal allograft recipients in the era of modern immunosupression. Transplantation Proceedings. 2011;43:2617-2623. Reference #2: Ewert R, et al. Abnormalities of Pulmonary Diffusion Capacity in Long-term Survivors After Kidney Transplantation. Chest. 2002;122(2):639-644. DISCLOSURE: The following authors have nothing to disclose: Landon Casaus, Sapna Bhatia, Ali Saeed, Rodrigo Vazquez Guillamet, Samuel Reynolds, Loren Ketai No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.461
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
434A
[
152#4S CHEST OCTOBER 2017
]