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Post-Transplantation Lymphoproliferative Disorder in the Renal Transplant Ureter
0022-5347/96/1556-2025$03.00/0
THEJOURNAL OF UROLOGY
Vol. 156,2026, June 1996 Printed in U S A .
Copyright 0 1996 by AMERICAN UROLDXCAL. ASS~CIATION, bc.
POST-TRANSPLANTATIONLYMPHOPROLIFERATrVE DISORDER IN THE RENAL TRANSPLANT URETER M. FERDA SENEL, CHARLES T. VAN BUREN, SHIRLEY RIGGS, JAMES CLARK, 111, WHITSON B. ETHERIDGE AND BARRY D. KAHAN* From the Division of Immunology and Organ Transplantation.Department of Surgery, University of Texas Medical Schoo~-Houston, Houston, Teros
KEY WORDS:ureter, kidney transplantation, lymphoproliferative disorders
Chronic alloantigenic stimulation may evoke posttransplantation lymphoproliferative disorder, which predominantly occurs at extranodal sites, and has a pleomorphic appearance and a strong causal association with EpsteinBarr virus infection.1
CASE REPORT
A 62-year-old white man with renal failure secondary to polycystic kidney disease received a cadaveric kidney from a 2 DR-matched, 14-year-old boy by end-to-side vascular and Lich ureteroneocystostomy anastomotic techniques in February 1993. Immunosuppression was induced intravenously with 3 mg.kg. cyclosporine, and corticosteroids tapering from 500 to 30 mg. by day 7. Because the donor tested positive for cytomegalovirus and Epstein-Barr virus, the recipient was treated with 200 mg. acyclovir orally 4 times daily for 3 months for prophylaxis. Only the Epstein-Bam virus IgG titer was positive (1:640)in the recipient. After a convalescence free of rejection episodes or clinical infections the recipient presented 3 months postoperatively with serum creatinine increased to 4.9 mg./dl. from a nadir of 1.5 mg./dl. (normal 0.5 to 1.4) in the absence of lymphadeFIG.1. Antegrade nephrosto am of transplant kidney shows dinopathy, organomegaly, fever, night sweats or weight loss, lated collecting system due to ureteral obstruction (arrow). and while receiving 20 mg. prednisone and 7 mg./kg. cyclosporine daily. Cyclosporine trough levels measured by selective antibody fluorescence polarization immunoassay ranged from 300 to 400 ng./ml. Ultrasound showed hydronephrosis and an antegrade nephrostogram demonstrated distal ureteral stenosis (fig. 1).Percutaneous renal biopsy revealed borderline acute cellular rejection (Banff classification). End-to-side ureteroureterostomy was performed. Histopathological evaluation showed atypical B-cell lymphocytes (nonHodgkin's lymphoma) in the resected 4 cm. distal ureteral segment (fig. 2). Serum electrophoresis revealed a monoclonal IgG kappa protein spike. Polymerase chain reactions demonstrated rearrangement of the immunoglobulin heavy chain genes. In situ deoxyribonucleic acid hybridization showed Epstein-Barr virus. Bone marrow biopsy, chest x-ray, and abdominal, pelvic and brain computerized tomography were negative. Cyclosporine was decreased to 5 mg./ kg. daily and prednisone was decreased to 10 mg. daily. At FIG.2. Large cell lymphoma with invasion and replacement of discharge home serum creatinine was 2.2 mg./dl. At 19 urothelium and lamina propria. H & E, reduced from X200. months serial computerized tomography is negative and serum creatinine is 2.9 mg./dl. In conclusion, in contrast to 2 REFERENCES previously reported cases of polyclonal lymphoma of a trans1. Craig, F. E., Gulley, M. L. and Banks, P. M.: Posttransplantation planted ureter2 and lymphoma in the renal h i l ~ r nour , ~ case lymphoproliferatiw disorders. h e r . J. Clin. Path., 9%265,1993. represents a monoclonal neoplasm. 2. Delbello, M. W.,Dick, W.H., Carter, C. B. and Butler, F. 0.: Dr. Jacki Abrams prepared the histopathology samples. Polyclonal B cell lymphoma of renal transplant ureter induced by cyclosporine: case report. J. Urol., 146: 1613, 1991. 3. Palmer, B. F., Sagalowsky, A. I., McQuitty, D. A., Dawidson, L.,
Eta1
Accepted for publication December 1, 1995. * Requests for reprints: Division of Immunology and Organ Translantation, Department of Surgery, University of Texas Medical Lhd-Houston, 6431 Fannin, Suite 6.240,Houston, Texas 77030. 2025
Vazquez, M. A. and Lu, C . Y . : Lymphoproliferative disease presenting as obstructive uropathy after renal transplantation. J. Urol., 153: 392, 1995.
THEJOURNAL OF UROLOGY
Vol. 156,2026, June 1996 Printed in U S A .
Copyright 0 1996 by AMERICAN UROLDXCAL. ASS~CIATION, bc.
POST-TRANSPLANTATIONLYMPHOPROLIFERATrVE DISORDER IN THE RENAL TRANSPLANT URETER M. FERDA SENEL, CHARLES T. VAN BUREN, SHIRLEY RIGGS, JAMES CLARK, 111, WHITSON B. ETHERIDGE AND BARRY D. KAHAN* From the Division of Immunology and Organ Transplantation.Department of Surgery, University of Texas Medical Schoo~-Houston, Houston, Teros
KEY WORDS:ureter, kidney transplantation, lymphoproliferative disorders
Chronic alloantigenic stimulation may evoke posttransplantation lymphoproliferative disorder, which predominantly occurs at extranodal sites, and has a pleomorphic appearance and a strong causal association with EpsteinBarr virus infection.1
CASE REPORT
A 62-year-old white man with renal failure secondary to polycystic kidney disease received a cadaveric kidney from a 2 DR-matched, 14-year-old boy by end-to-side vascular and Lich ureteroneocystostomy anastomotic techniques in February 1993. Immunosuppression was induced intravenously with 3 mg.kg. cyclosporine, and corticosteroids tapering from 500 to 30 mg. by day 7. Because the donor tested positive for cytomegalovirus and Epstein-Barr virus, the recipient was treated with 200 mg. acyclovir orally 4 times daily for 3 months for prophylaxis. Only the Epstein-Bam virus IgG titer was positive (1:640)in the recipient. After a convalescence free of rejection episodes or clinical infections the recipient presented 3 months postoperatively with serum creatinine increased to 4.9 mg./dl. from a nadir of 1.5 mg./dl. (normal 0.5 to 1.4) in the absence of lymphadeFIG.1. Antegrade nephrosto am of transplant kidney shows dinopathy, organomegaly, fever, night sweats or weight loss, lated collecting system due to ureteral obstruction (arrow). and while receiving 20 mg. prednisone and 7 mg./kg. cyclosporine daily. Cyclosporine trough levels measured by selective antibody fluorescence polarization immunoassay ranged from 300 to 400 ng./ml. Ultrasound showed hydronephrosis and an antegrade nephrostogram demonstrated distal ureteral stenosis (fig. 1).Percutaneous renal biopsy revealed borderline acute cellular rejection (Banff classification). End-to-side ureteroureterostomy was performed. Histopathological evaluation showed atypical B-cell lymphocytes (nonHodgkin's lymphoma) in the resected 4 cm. distal ureteral segment (fig. 2). Serum electrophoresis revealed a monoclonal IgG kappa protein spike. Polymerase chain reactions demonstrated rearrangement of the immunoglobulin heavy chain genes. In situ deoxyribonucleic acid hybridization showed Epstein-Barr virus. Bone marrow biopsy, chest x-ray, and abdominal, pelvic and brain computerized tomography were negative. Cyclosporine was decreased to 5 mg./ kg. daily and prednisone was decreased to 10 mg. daily. At FIG.2. Large cell lymphoma with invasion and replacement of discharge home serum creatinine was 2.2 mg./dl. At 19 urothelium and lamina propria. H & E, reduced from X200. months serial computerized tomography is negative and serum creatinine is 2.9 mg./dl. In conclusion, in contrast to 2 REFERENCES previously reported cases of polyclonal lymphoma of a trans1. Craig, F. E., Gulley, M. L. and Banks, P. M.: Posttransplantation planted ureter2 and lymphoma in the renal h i l ~ r nour , ~ case lymphoproliferatiw disorders. h e r . J. Clin. Path., 9%265,1993. represents a monoclonal neoplasm. 2. Delbello, M. W.,Dick, W.H., Carter, C. B. and Butler, F. 0.: Dr. Jacki Abrams prepared the histopathology samples. Polyclonal B cell lymphoma of renal transplant ureter induced by cyclosporine: case report. J. Urol., 146: 1613, 1991. 3. Palmer, B. F., Sagalowsky, A. I., McQuitty, D. A., Dawidson, L.,
Eta1
Accepted for publication December 1, 1995. * Requests for reprints: Division of Immunology and Organ Translantation, Department of Surgery, University of Texas Medical Lhd-Houston, 6431 Fannin, Suite 6.240,Houston, Texas 77030. 2025
Vazquez, M. A. and Lu, C . Y . : Lymphoproliferative disease presenting as obstructive uropathy after renal transplantation. J. Urol., 153: 392, 1995.