Autopsy case of miliary tuberculosis with cerebral involvement in renal failure

We encountered an autopsy case of renal failure complicated by cerebral tuberculosis. The patient was hospitalized due to disturbance of consciousness, and dialysis therapy was performed because of end-stage renal failure. Approximately 1 week later, abnormal shadows were observed on chest X-ray, and various examinations were performed until the diagnosis was finally determined as miliary tuberculosis. Disturbance of consciousness was exacerbated, despite the administration of antituberculosis drugs and other treatments, and the patient died on the 105th hospital day. Pathological examinations demonstrated miliary tuberculosis associated with intracranial involvement, in addition to contracted kidneys. In patients with end-stage renal failure, the risk of developing tuberculosis, miliary tuberculosis in particular, is reported to be much higher than in normal subjects. However, the diagnosis of miliary tuberculosis is difficult to establish, because of nonspecific symptoms and the low rate of detection of acid-fast bacteria from the sputum. Comprehensive understanding of the results of frequent culture examinations of sputum and blood, contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), and Polymerase chain reaction (PCR) of cerebrospinal fluid, as well as albumin concentration in the cerebrospinal fluid, are considered useful in diagnosing intracranial tuberculosis. Although cerebral tuberculoma is rare, prolonged disturbance of consciousness may be related to cerebral tuberculosis. Therefore, particular attention should be paid to patients with end-stage renal failure complicated by disturbance of consciousness. Received: October 9, 1998 / Accepted: February 23, 1999     

A lucky fall? Case report

Renal cell carcinomas (RCCs) account for 3% of all solid neoplasms, with an increased incidence after renal transplantation. In transplant recipients, RCCs predominantly occur in the patient's native kidneys. Herein is reported a case of a localized RCC of recipient origin that developed in the donor allograft and was detected 8 years after renal transplantation. Treatment with high-intensity focussed ultrasound followed by partial nephrectomy was successful, averting the need for dialysis therapy.     

A Rare Manifestation of Tuberculosis in a Renal Transplant Patient: A Case Report

Cutaneous lesions in the presence of fever in patients undergoing immunosuppressive therapy are a diagnostic challenge and may represent manifestations of multiple diseases, such as fungal infections, nocardiosis, lymphoproliferative diseases, zoonosis, and tuberculosis. The authors report a case of a 66-year-old white man with chronic kidney disease since 2014 (chronic pyelonephritis) who had a renal transplant in the previous 6 months. Induction therapy was performed with thymoglobulin, and his current immunosuppression scheme included tacrolimus, mycophenolate mofetil, and prednisolone. The patient had no history of pulmonary tuberculosis. The patient presented with 2 cutaneous lesions, localized on the back and abdomen, that appeared to be firm, painful, subcutaneous, erythematous nodules with an approximately 5 cm diameter overlying an infected focus and purulent material inside. The patient also had a fever and fatigue. Blood analysis showed pancytopenia with an elevation of inflammatory markers and graft dysfunction. Tissue cultures and skin biopsy with histological analysis were performed. Histopathology of the lesion showed a nonspecific inflammatory infiltrate without granulomas, and acid-fast bacillus staining was negative. Nevertheless, serum QuantiFERON testing was positive. But polymerase chain reaction finally confirmed the presence of Mycobacterium tuberculosis, which confirmed the diagnosis of cutaneous tuberculosis. A chest computed tomography scan showed a lung pattern of miliary tuberculosis. The patient was treated with multidrug tuberculosis therapy, resulting in lesion clearance after 3 weeks. Tuberculosis is a serious infection, especially in high-risk patients, such as those in an immunocompromised state. The incidence of cutaneous tuberculosis is rare, but it should be considered in patients presenting with atypical skin lesions suggestive of an underlying infectious etiology.     

Acute renal failure due to leptospirosis in a renal transplant recipient: a brief review of the literature

We present the case of a 43-year-old renal transplant patient who presented with fever, malaise, pruritus, headache, and severe jaundice of 3-week duration following work in a rice field. He was found to have acute renal failure and severe hyperbilirubinemia with a positive serum leptospira antibody titer, making the diagnosis of Weil's disease. The patient responded to reduction in immunosuppressive medications and intravenous penicillin therapy with no need for dialysis. This is the second case of leptospirosis in a kidney transplant patient reported in the English literature.     

Length of time on dialysis prior to renal transplantation is a critical factor affecting patient survival after allografting

Within the past year at our transplant center we have had the experience of performing renal allografts in two patients older than 65 years, each of whom had been on hemodialysis more than 10 years. Both resulted in patient mortality within 90 days of transplant (one due to myocardial infarction, the other due to visceral ischemia with infarction). This prompted us to review retrospectively our own data (n = 204) and the national (UNOS) data (n = 10 971) regarding transplant outcome, patient age, and length of time on dialysis prior to renal transplantation. This review revealed that patient mortality after transplant increased with the length of end-stage renal disease (dialysis, regardless of type) independent of age, the greatest mortality occurring within the first 6 months of transplant (and not thereafter); graft survival was similar for all age cohorts analyzed. Our review of the literature reveals a paucity of articles pertaining to post-transplant mortality and length of time on dialysis prior to transplant. Our results indicate the following possible conclusions. (1) The length of time of end-stage renal disease therapy prior to renal transplantation is a significant and independent risk factor for post-transplant mortality. (2) Higher priority should be given to this factor when formulating strategies for allocation of scarce resources. (3) Patients on dialysis for extended periods of time who are elderly may be at particularly high risk. (4) Patients being considered for renal transplant should be informed of their individual risk factors for mortality post-transplant based on length of ESRD therapy. (5) Renal transplantation should be considered as early as possible in patients with ESRD (or imminent ESRD).     

Successful treatment of mucormycosis in a renal allograft recipient

INTRODUCTION: Mucormycosis is a rare but potentially lethal fungal infection in renal allograft recipients with rhinocerebral mucormycosis is the most common presentation. The usual infection route is inhalation of the spores, but certain procedures such as intravenous cannulation and bladder catheterization are often the cause of infection. CASE: A 50-year-old female dermatologist received an allograft from an emotionally related living donor, 24-year-old male with the same blood group and 3/6 mismatches. After severe attack of acute vascular rejection associated with rupture graft, that was managed properly she developed rinocereral mucormycosis. It was diagnosed early and aggressively treated with amphoteracin B and carefully monitored with favourable graft and patient survival. Up to our knowledge, this is the first case of renal transplant with extrarenal-ethemoidal sinus-mucor infection associated with acute vascular rejection that in spite of aggressive anti-rejection therapies with methylprednisolone, rituximab and plasma exchange, had favourable outcome in terms of graft and patient survival. CONCLUSION: Mucormycosis in a renal allograft recipient is an extremely rare and potentially lethal complication. Aggressive anti-rejection therapy is a risk factor for the development of this unfavourable outcome. Early diagnosis, aggressive treatment with amphoteracin B and careful monitoring can be helpful in treating these patients and achieve favourable prognosis.     

Infection with human immunodeficiency virus in the Pittsburgh transplant population. A study of 583 donors and 1043 recipients, 1981-1986

We performed a retrospective serologic survey of 583 organ donors and 1043 transplant recipients for antibodies to human immunodeficiency virus type 1 (HIV-1). Two (0.34%) of the 583 donors and 18 (1.7%) of the 1043 recipients had HIV-1 antibodies by enzyme immunoassay and by Western blot. Two of 5 seropositive recipients tested also had blood cultures positive for HIV-1. Seven (0.7%) of the 1043 transplant recipients had antibodies to HIV-1 before transplantation; 2 of these had hemophilia A, and 5 had previous transfusions. Eleven (1.3%) of 860 recipients followed for 45 days or more seroconverted to HIV-1 a mean of 96 days after transplantation. Likely sources of HIV-1 infection for 3 of these 11 recipients included a seropositive organ donor in 1 patient and high-risk blood donors in 2 patients. A definite source of HIV-1 infection was not found for the other 8 recipients, 3 of whom seroconverted to HIV-1 after institution of blood donor screening for HIV-1 antibodies. Seroconversion to HIV-1 was less common in kidney recipients than in liver, heart, or multiple-organ recipients (P less than 0.02). Nine (50%) of the 18 HIV-1 seropositive transplant recipients died a mean of 6 months after transplant surgery, and 9 (50%) are still alive a mean of 43 months after transplantation. AIDS-like illnesses occurred in 3 of the dead and 1 of the living patients and included pneumocystis pneumonia (3 cases), miliary tuberculosis (1 case), and recurrent cytomegalovirus infection (1 case). These data suggest that the course of HIV-1 infection is not more severe in transplant recipients receiving cyclosporine than in other hosts and that, despite screening of blood and organ donors, a small number of transplant recipients will become infected with HIV-1.     

Case Report: First Reported Combined Heart-Liver Transplant in a Patient With a Congenital Solitary Kidney

We report a case of successful combined heart liver transplant in a patient with a congenital solitary kidney. The patient had normal renal function before combined heart-liver transplantation and developed acute kidney injury requiring slow continuous dialysis and subsequent intermittent dialysis for almost 8 weeks post transplantation. Her renal function recovered and she remains off dialysis now 7 months post transplantation. She only currently has mild chronic renal insufficiency. We believe this is the first reported case of successful heart liver transplant in a patient with a congenital solitary kidney.     

Posttransplant Mycobacterium tuberculosis disease following liver transplantation and the need for cautious evaluation of Quantiferon TB GOLD results in the transplant setting: a case report

This report describes a case of pulmonary tuberculosis in a liver transplant patient without a history of previous exposure to Mycobacterium tuberculosis (MTB) complex. Prior to transplantation, the tuberculin skin test was negative and the QuantiFERON-TB Gold (QFT Gold), an interferon gamma-based blood test, was negative before and after transplant including a period beginning on postoperative day 55 when the patient developed a febrile illness with an interstitial infiltrate and pleural effusion that was unresponsive to broad-spectrum antibiotic therapy. Empiric treatment with isoniazid, ethambutol, and levofloxacin resulted in resolution of the clinical symptoms. A sputum culture grew MTB on postoperative day 87. This case illustrates the need for caution when QFT Gold is used as diagnostic tool for latent tuberculosis during the pretransplant assessment. Further studies evaluating the usefulness of QFT Gold and other interferon gamma tests in posttransplantation active infection are warranted.     

Post-transplant diabetes mellitus in renal allograft recipients: a matched-pair control study

The incidence of post-transplant diabetes mellitus was evaluated retrospectively in 901 consecutive renal transplant recipients. Thirty-two (3.6%) patients developed diabetes mellitus requiring drug therapy. 18 of 32 became hyperglycaemic within 3 months of transplantation. Post-transplant diabetes mellitus occurred in 24 of 628 (3.8%) patients treated with conventional therapy consisting in azathioprine and prednisone, and in 8 of 273 (2.9%) patients receiving cyclosporin A (CsA) in addition (triple therapy). To identify predisposing factors 32 non-diabetic patients matched for age, sex, number of graft, immunosuppressive protocol, and graft function at onset of diabetes were used as case controls. Thirteen of 32 patients with diabetes mellitus and 5 of 32 control patients had abnormal glucose tolerance pretransplant (P less than 0.025). HLA-B8 was significantly more frequent in patients with post-transplant diabetes mellitus than in control patients (9 of 29 vs 2 of 31, P less than 0.02). Twelve (38%) patients became diabetic during or immediately after anti-rejection therapy with intravenous pulse prednisone. Four diabetic patients experienced chronic pancreatitis pre-transplant. Family history of diabetes mellitus, bodyweight, number of rejection episodes, and immunosuppressive drug doses were similar in both groups. Actuarial patient and graft survival was not significantly different in diabetic patients and controls, although 10-year data tended to be better in controls. Thus, post-transplant diabetes mellitus was not a frequent complication in patients sometimes predisposed by an impaired glucose tolerance pre-transplant and was triggered by pulse prednisone therapy in 38%.     

Severe anaphylactoid reaction to thymoglobulin in a pediatric renal transplant recipient

Intraoperative administration of thymoglobulin is an integral part of the anti-rejection regimen during organ transplantation. However, its administration may be associated with complications. An anaphylactoid reaction that occurred in a pediatric recipient of a living-related renal transplant, on initiating an intravenous infusion of thymoglobulin, is presented.     

Renal transplantation offers a better survival in HCV-infected ESRD patients

Sezer S, Ozdemir FN, Akcay A, Arat Z, Boyacioglu S, Haberal M. Renal transplantation offers a better survival in HCV-infected ESRD patients. Clin Transplant 2004 DOI: 10.1111/j.1399-0012.2004.00252.x Copyright Blackwell Munksgaard, 2004Abstract: The presence of hepatitis C virus (HCV) infection has been found to adversely affect the morbidity and mortality rates in the dialysis population. Renal transplantation is a treatment option after a careful pre-transplant evaluation. We designed this study to find the impact of HCV infection on patient survival, co-morbidity and allograft survival in a selected group of hemodialysis (HD) and transplant population. We retrospectively analyzed 116 renal transplant patients (94 HCV-negative, 22 HCV-positive) and 136 HD patients (106 HCV-negative, 30 HCV-positive) who had renal transplantation or underwent dialysis before 1996. The HCV-infected patients were evaluated by liver biopsy for the absence of advanced liver disease before transplantation. There was no clinical or laboratory decompensation of liver disease in transplant and dialysis patient groups. The overall 5-yr survival rates were 85.2% for renal transplant recipients and 74.5% for those on HD. The comparison results revealed a significant difference between HCV-infected patients with and without transplantation. The 3-yr renal allograft survival rates were comparable in HCV-positive and -negative patients, but the risk of chronic allograft nephropathy (CAN) and graft failure were higher at the fifth year in HCV-positive patients. In conclusion, renal transplantation should the preferred therapy in HCV-infected dialysis patients as it improves the survival rates. The presence of HCV infection increases the CAN rate and the influence on allograft survival is evident at the fifth year of assessment.     

Treatment of Parvovirus B-19 (PV B-19) Infection Allows for Successful Kidney Transplantation Without Disease Recurrence

Parvovirus B 19 (PV-B19) has emerged as a cause of glomerulopathy in native and transplanted kidneys. Disease recurrence is less well described. The clinical and pathological spectrum of PV-B19 infection can be quite variable and therefore easily missed. There are no data regarding the safety of transplantation in PV-B19-infected patients. We diagnosed a kidney transplant patient with recurrent PV-B19 infection and collapsing glomerulopathy (CG) on renal biopsy. Retrospective analysis of stored serum showed that PV-B19 DNA was present prior to the transplant. The patient was treated with intravenous immunoglobulin (IVIG), and eventually the virus was successfully eradicated after allograft loss and discontinuation of immunosuppressive medications. The patient subsequently received her fourth kidney transplant. Polymerase chain reaction (PCR) for PV-B19 DNA was negative on multiple occasions for approximately 1 year prior to her transplant. The patient is now 22 months post transplantation, quarterly serum PCRs continue to be negative for PV-B19 DNA despite reinstitution of immunosuppressive therapy. The patient's renal function remains stable with a serum creatinine of 0.9 mg/dL and a serum albumin of 4.2 g/dL. Successful diagnosis and treatment of PV-B19 viremia appears to allow for successful transplantation without evidence of disease recurrence. Since PV-B19 can cause significant morbidity post transplant, it is important to screen potential transplant candidates at risk for PV-B19 infection pre transplant. Careful surveillance post transplantation is necessary to identify disease recurrence so that early treatment can be initiated.     

Intractable recurrent hepatitis A virus infection requiring repeated liver transplantation: a case report

Although hepatitis A virus (HAV) infection is usually self-limited, it may induce fulminant hepatitis. We present an unusual case of a 40-year-old, otherwise healthy man with intractable recurrent HAV infection requiring retransplantation after primary liver transplantation for HAV-associated fulminant liver failure. After the first living-donor liver transplantation, allograft function recovered uneventfully; however, beginning at 35 days, his serum total bilirubin concentration increased, reaching 40 mg/dL, with a slight increase in liver enzymes. Detection of genomic HAV RNA in serum at the time of graft dysfunction led to a diagnosis of recurrent HAV infection. Fifty-one days after the first transplant, he underwent a deceased donor retransplantation. His allograft function recovered; the patient was discharged from the hospital. Sixty-five days later, however, he was readmitted for colitis-like symptoms and was again treated for acute rejection, but died owing to overwhelming sepsis and persistence of HAV infection. These findings indicate that patients who undergo liver transplantation for HAV-associated liver disease may be at risk of HAV reinfection, particularly if they require anti-rejection therapy. Routine measurements of anti-HAV immunoglobulin M and HAV RNA during the early posttransplant period in HAV-associated liver transplant recipients may differentiate reinfection from an acute cellular rejection episode.     

Prevention of sepsis during the transition to dialysis may improve the survival of transplant failure patients

Dialysis patients are at risk for sepsis, and the risk may be even higher among transplant failure patients because of previous or ongoing immunosuppression. The incidence and the consequences of sepsis as defined by International Classification of Diseases, Ninth Revision, Clinical Modification hospital discharge diagnoses codes were determined among 5117 patients who initiated dialysis after transplant failure between 1995 and 2004 in the United States. The overall sepsis rate was 11.8 per 100 patient years (95% confidence interval [CI] 11.5 to 12.1). Sepsis was highest in the first 6 mo after transplant failure (35.6 per 100 patient years [95% CI 29.4 to 43.0] between 0 to 3 mo after transplant failure; 19.7 per 100 patient years [95% CI 17.2 to 22.5] between 3 to 6 mo after transplant failure). In comparison, the sepsis rate among incident dialysis patients between 3 and 6 mo after dialysis initiation was 7.8 per 100 patient years (95% CI 7.3 to 8.3), whereas the sepsis rate among transplant recipients between 3 and 6 mo after transplantation was 5.4 per 100 patient years (95% CI 4.9 to 5.9). Patients who were > or =60 yr, obese patients, patients with diabetes, and patients with a history or peripheral vascular disease or congestive heart failure were at risk for sepsis. Transplant nephrectomy was not associated with septicemia. The role of continued immunosuppression and vascular access creation was not assessed and should be addressed in future studies. In a multivariate analysis, patients who were hospitalized for sepsis had an increased risk for death (hazard ratio 2.93; 95% CI 2.64 to 3.24; P < 0.001). Strategies to prevent sepsis during the transition from transplantation to dialysis may improve the survival of patients with allograft failure.     

Clinical features and severity of nonspecific symptoms in dialysis patients

Nonspecific symptoms are common in dialysis patients but few methods are available to measure their severity and their response to alteration in dialysis therapy. To determine the clinical features and measure the severity of the most important symptoms in end-stage renal disease (ESRD) patients, 97 dialysis patients were interviewed, 63 of whom were reinterviewed 1 year later. For comparison 82 transplant recipients were also interviewed. The six most important symptoms in dialysis patients (using the product of the patient's perception of severity and prevalence) were tiredness, cramps, pruritus, dyspnea, headaches and joint pain. The symptoms were long-standing, occurred frequently, with little difference in prevalence between hemo- and peritoneal dialysis patients, and were often unrelated to a hemodialysis session. For each symptom, several dimensions of severity were assessed including frequency, duration, effect on sleep, daily living, activity, subjective quality of life and necessity for drug therapy. Often these dimensions did not correlate with patient's perception of severity. For each symptom these items were combined to give an aggregate score with a range 0-10. Interobserver reproducibility for each symptom score was greater than or equal to 0.7 but intraobserver reproducibility was poor for 3 symptoms, because of the fluctuating nature of the symptoms. Construct validity was demonstrated by finding a significantly worse distribution of aggregate scores for tiredness, cramps, pruritus, dyspnea and nausea/vomiting in dialysis compared to transplant patients. Aggregate scores changed little after 1 year's follow-up in stable dialysis patients but significant improvement in the aggregate scores for tiredness, dyspnea and nausea/vomiting were observed in 14 patients after successful transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)     

BK polyomavirus interstitial nephritis in a renal transplant patient with no previous acute rejection episodes

A renal transplant patient treated with tacrolimus and mycophenolate-mofetil (MMF) developed progressive graft function deterioration 10 months after transplantation. Biopsy of the graft showed severe, focally accentuated interstitial inflammation with focal tubulitis and tubular necrosis, and medium-severe interstitial fibrosis with focal tubular atrophy. Glomerular and vascular structures were preserved. On careful examination, in some sections, tubular epithelial cells showed a definite increase with deformation of the nuclear shape, chromatin irregularities with peripheral dislocation and inclusion bodies. These cytopathic changes suggested polyoma virus infection ("decoy cells"). Subsequent screening of the urinary sediment confirmed the presence of many "decoy cells". Immunohistochemical analysis of the biopsy showed many tubular cells were strongly positive for the SV 40 antigen, specific for BK polyoma virus. A diagnosis of interstitial nephritis due to BK polyoma virus was made, though the coexistence of cellular rejection could not be excluded. At variance with previous reports, our patient had not had repeated episodes of rejection before biopsy or heavy immunosuppressive treatment, such as ALG, OKT3, after transplantation. This case shows that even in the absence of vigorous anti-rejection therapy an immunosuppressive regimen based on tacrolimus and MMF may involve the risk of BK polyoma virus- associated interstitial nephritis.     

Case report of skin tuberculosis after living renal transplantation

We report on a mycobacterium tuberculosis after renal transplantation. This is, to our knowledge, the first case report on an isolated skin tuberculosis with mycobacterium tuberculosis after renal transplantation. A-68-year-old renal transplant recipient presented with a nodule in his right breast. A diagnosis of a mycobacterium tuberculosis skin infection was made and antimycobacterial therapy was started.     

Evaluation of adult kidney transplant candidates

Important advances in immunosuppressive therapy and refinement in surgical techniques have allowed renal transplantation to become the treatment of choice for virtually all suitable candidates with end-stage renal disease. Compared to dialysis, kidney transplantation improves both patient survival and quality of life and, over time, can reduce the total cost of medical care. It must be noted, however, that although the risk of death in the first year after transplantation is <5%, not all patients qualify for the surgery because of their unacceptable risks for complications. The transplant evaluation process requires a comprehensive assessment of each patient's medical, surgical, and psychosocial histories. Selection of the suitable transplant candidate remains a challenge for transplant physicians owing, predominantly, to the presence of complex medical issues in the potential candidates and nonstandardized criteria for acceptance or rejection among transplant centers. Furthermore, with the ever-increasing disparity between donor organ supply and demand and resultant increased wait-list times, the transplant physicians must further consider the optimal management and re-evaluation of wait-list patients during the waiting period. This article describes a systematic approach for the evaluation of a potential renal transplant candidate. Various medical issues that arise during the evaluation process are discussed.     

Does ethnicity influence perceived quality of life of patients on dialysis and following renal transplant?

BACKGROUND: Quality of life (QoL) as perceived by patients with end-stage renal disease (ESRD) is an important measure of patient outcome. There is a high incidence of ESRD in the Indo-Asian population in the UK and a lower rate of transplantation compared with white Europeans. The aim of this study was to determine whether perceived quality of life was influenced by treatment modality and ethnicity. METHODS: Sixty Indo-Asians treated with either peritoneal dialysis (n=20), hospital haemodialysis (n=20) or with a renal transplant (n=20) for >3 months were compared with 60 age-matched white Europeans closely matched for gender, diabetes and duration of renal replacement therapy. QoL was measured using the Kidney Disease and Quality of Life questionnaire (KDQOL-SF). The KDQOL-SF measures four QoL dimensions: physical health (PH), mental health (MH), kidney disease-targeted issues (KDI) and patient satisfaction (PS). Adequacy of treatment was measured by biochemistry, 24 h urine collection and dialysis kinetics. The number of comorbid conditions was scored. Social deprivation was calculated from the patient's postal address using Townsend scoring. RESULTS: QoL was significantly lower in Indo-Asians than white Europeans for PH, MH and KDI. This was not related to treatment adequacy, which was similar in both for each modality. Indo-Asians had a worse index of social deprivation than white Europeans (P=0.008). PH and KDI were related to social deprivation (P=0.007 and P=0.005, respectively). QoL (except PS) was inversely correlated with comorbidity. Dialysis patients had higher comorbidity than transplant patients (P<0.02). Comparing only those dialysis patients considered fit for transplantation (n=51) with transplant patients, comorbidity was similar, but differences in QoL persisted. CONCLUSION: This study demonstrates a lower perceived QoL in Asians compared with white Europeans with ESRD. Analysis of QoL indicates that Asian patients in particular perceive kidney disease as a social burden, even if successfully transplanted.