case presentation lorraine c. racusen md fasn the johns hopkins university school of medicine
TRANSCRIPT
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Case Presentation
Lorraine C. Racusen MD FASN
The Johns Hopkins University School of Medicine
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Case History – Pre-transplant
52 y/o white female H/O obesity, HTN, Hashimoto’s thyroiditis,
multiple drug allergies Diagnosed with CNS sarcoidosis in 2004,
with pulmonary and renal involvement Developed Stage IV CKD
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Case History - Transplant
Pre-emptive compatible live donor transplant June 2009
Highly sensitized – husband donated to a paired kidney exchange program to ensure an optimally matched donor
Post-transplant- creatinine decreased to 1.2 mg/dl at discharge
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Case History – Post-transplant
Problems with urinary retention, UTIs – renal function remained excellent
In August 2010 – presented with a large incisional hernia and left adnexal cyst
Meds: Tacrolimus, MMF, prednisone, Exatimibe, metoprolol, oxycodone, Prilosec
In January 2011- admitted for hernia repair with mesh placement
“Incidental biopsy done during surgery
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Pathology Findings
Glomeruli – focal ischemia only Tubulointerstitium – intensely inflamed in
50%, mildly inflamed elsewhere- lympho- plasmacytic with focal eosinophils and numerous non-caseating granulomas with giant cells; early evolving fibrosis
Stains for fungi, AFB- negative IP stain for PPV (SV40 large T antigen)
negative
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Pathology Diagnoses
Granulomatous interstitial nephritis consistent with recurrent sarcoidosis – R/O infection, R/O drug reaction
Lymphocytic tubulitis – cannot rule out cell-mediated rejection
Evolving interstitial fibrosis and tubular atrophy, moderate
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Granulomatous IN - causes
Infection – bacterial (brucellosis, AFB), fungal Drugs- antibiotics, allopurinol, furosemide, HCTZ,
omeprazole, NSAIDs, bisphosphonates, carbamazepine, oxycodone
Tubulointerstitial nephritis with uveitis (TINU) Oxalosis Gout Sarcoidosis Idiopathic
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Follow-up studies Infection
Stains for AFB, fungi negative
Urine culture for fungi and AFB- negative
Brucellosis titers- negative Drugs
Prilosec/omeprazole – IN may be very indolent clinically
Oxycodone – reported in drug abuse cases using drug
from suppositories – probably due to adulterant TINU, oxalosis, gout- no relevant findings for these Sarcoidosis – major possibility given the history
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Recurrence of Sarcoidosis in Transplants
Described in lung allografts (eg Milman et al, Eur Resp J, 2005)
Described in hepatic allografts (eg Hunt J et al, 1999; Cezig C et al 2005, Abraham SC et al 2008)
A few cases in renal allografts (Shea SY et al 1986; Kakura S et al 2004, Brown JH et al 1992, Vargas F et al 2010
Incidence of recurrence unknown – some cases are associated with organ dysfunction +/- hypercalcemia, but SOME DETECTED IN STABLE GRAFTS, as in this case
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Recurrent sarcoidosis - Kidney
Some cases detected on protocol biopsy Lymphocytic tubulitis common In one case (Shea SY et al)- there was
granulomatous uveitis and arteritis, and positive tuberculin skin test- ?!?
Treatment with steroids usually efficacious- must rule out infection
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Case – Follow-up After evaluation for infection, begun on high-dose steroid
therapy with plan to re-biopsy after 8 weeks;
also begun on Fluconazole for Candida esophagitis;
discharge creatinine 1.2 Readmitted for acute arterial clot- placed on Coumadin In mid-February, admitted for HSV esophagitis- begun on
Acyclovir; creatinine 3.3 improved to 2.7 By April 2011 – creatinine 1.7 In July 2011- creatinine 1.6; still on Coumadin- no kidney
re-biopsy performed
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