case presentation lorraine c. racusen md fasn the johns hopkins university school of medicine
TRANSCRIPT
Case Presentation
Lorraine C. Racusen MD FASN
The Johns Hopkins University School of Medicine
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
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
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
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
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
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
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
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
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
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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